Lacerating the barricade: A challenging case of TAVR/TMVR with concomitant LAMPOON and BASILICA procedures
Presenter
Kirtivardhan Vashistha, M.D., Allegheny General Hospital, Pittsburgh, PA
Amel Tobaa, M.D.1, Kirtivardhan Vashistha, M.D.1, Adnan Khalif, M.D., FSCAI1, Colin Slemenda, D.O.2, Saad Tabbara, M.D., FSCAI2, David M. Lasorda, D.O., FSCAI1, Stephen Bailey, M.D.1 and Ramzi F. Khalil, M.D., FSCAI1, (1)Allegheny General Hospital, Pittsburgh, PA, (2)Allegheny Health Network, Pittsburgh, PA
Keywords: TAVI/TAVR/Aortic Valve
Title Lacerating the barricade: A challenging case of TAVR/TMVR with concomitant LAMPOON and BASILICA procedures Introduction Transcatheter valve replacement is indicated for patients with severe symptomatic valvular stenosis. In patients undergoing transcatheter aortic valve replacement (TAVR), protecting against coronary obstruction is key to avoiding complications. Similarly, in patients undergoing transcatheter mitral valve replacement (TMVR), preventing neo-LVOT (left ventricular outflow tract) obstruction is paramount. We present a unique case in which leaflet laceration techniques, LAMPOON and BASILICA were implemented concomitantly to minimize these procedural complications during TAVR/TMVR. Clinical Case A 70 year old woman with a history of bioprosthetic aortic and mitral valves (MV) presented for an evaluation of severe dyspnea on exertion. A transesophageal echocardiogram (TEE) showed an ejection fraction of 55-59 %, severe mitral and aortic valve stenosis and severe tricuspid regurgitation. Her cardiac catheterization showed mild to moderate coronary artery disease and severe calcification of the aortic annulus. She was deemed prohibitive risk for re-do sternotomy. A cardiac CT angiogram was performed for an evaluation of a transcatheter approach revealing effaced coronary sinus and low lying coronary arteries, putting her at a high risk of coronary occlusion post TAVR. Additionally, severe narrowing of the neo-LVOT (150 mm2) was observed, which put her at a high risk of LVOT obstruction post TMVR. Given these risks, the interventional team decided to proceed with TAVR/TMVR with concomitant LAMPOON (Intentional Laceration of Anterior Mitral leaflet to Prevent left ventricular Outflow tract Obstruction) and BASILICA (Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction). Initially the patient underwent TAVR with BASILICA with an intraoperative TEE revealing a drop in mean gradient (MG) from 31 mmhg at baseline to 11 mmhg, preserved flow in the left main coronary artery on color doppler, which was confirmed by coronary angiography. Following that she underwent TMVR with LAMPOON procedure and an intraoperative TEE at this time revealed a drop in MG to 3 mmhg, and non obstructed LVOT with MG of 13 mmhg. Post TMVR, AV MG further dropped to 6mmhg. She tolerated the procedure with resolution of her symptoms and was discharged in the next 48 hours. A year later, the patient remains asymptomatic. Discussion The procedural risks associated with transcatheter valve replacements have increased as the indications have grown to include patients across all risk spectrums. Two feared complications of these procedures include coronary and neo-LVOT obstruction. We present the first known report of combined upfront leaflet laceration techniques LAMPOON and BASILICA, to facilitate successful TMVR and TAVR in a patient with severe symptomatic valvular stenosis.