Left ventricle outflow tract obstruction after transcatheter mitral valve replacement with a transatrial approach

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A 74-year-old female with a history of transcatheter mitral valve replacement (TMVR) with a transatrial approach was referred to our institution due to progressive dyspnoea. The mitral intervention had been performed 2 years before with the use of a #29 Sapien bioprosthetic valve in the setting of severe mitral valve (MV) stenosis with extensive mitral annular calcification. Post-procedure, the patient developed complete heart block and a pacemaker was implanted.

Transthoracic echocardiography revealed adequate bioprosthetic valve gradients and trivial central regurgitation. However, the prosthetic valve strut was noted to be severely impinging the left ventricle outflow tract (LVOT) (Panel A; see Supplementary data online, Video S1), causing subvalvular obstruction (mean gradient 15 mmHg) (Panels B and C). Computed tomography showed bioprosthetic valve leaflets with excellent excursion but confirmed marked LVOT obstruction by the valve frame (Panels D and E, see Supplementary data online, Video S2). The neo-LVOT was ∼2 cm² in diastole, and it was nearly obliterated in systole (Panel F). A redo MV replacement was decided by the Heart-Team.

TMVR with a transatrial approach is a novel procedure, potentially beneficial for cases with severe MV calcification. This technique allows to remove the anterior mitral leaflet and to deploy the valve under direct visualization, thus potentially minimizing the risks of atrio-ventricular rupture following decalcification and of systolic anterior motion of the anterior leaflet. However, LVOT obstruction by the bioprosthesis can occur, as highlighted by this case. With the increase in therapeutic options for MV replacement, precise pre-operative evaluation is paramount to individualize the best procedure for each patient.

Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.

Funding: None declared.

Data availability: No new data were generated or analysed in support of this research.

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