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  • Surgical Bailout for Left Ventricular Outflow Tract Obstruction Following a Complicated Mitral Valve-in-Valve Procedure

    Introduction

    Transcatheter heart valve (THV) replacement as a therapy concept has established itself as an alternative to surgical valve replacement mostly on the heels of the success with transcatheter aortic valve replacement (TAVR) [1]. Earlier this year, reports from two trials on the successful use of TAVR in low surgical-risk patients have potentially further expanded indications for the use of THV [2,3]. Meanwhile, using THV in other valve positions, such as the tricuspid and mitral valve, has remained mostly investigational. This is due to a variety of reasons including the epidemiology of multiple valve pathologies, the exposure to systolic pressure gradients, and unique anatomic challenges with atrioventricular valves [4]. A dreaded complication with THV implantation in the mitral position is the possibility of left ventricular outflow tract obstruction (LVOTO) [5,6]. Because of the intricate relationship of the left ventricular in- and outflow path with minimal separation of the mitral and aortic valve – consisting solely of the dynamic aortomitral curtain – anterior protrusion from the mitral annular plane into the left ventricle can cause LVOTO. Although more common with native mitral valve TMVR (>50%), than with valve-in-ring (<10%) or valve-in-valve TMVR (<5%), this complication remains a serious concern [7]. It is extremely poorly tolerated from a hemodynamic standpoint and associated with a mortality >33% [6].

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