A new application of balloon-assisted translocation of the mitral anterior leaflet (BATMAN) has achieved a redo transcatheter mitral valve replacement (TMVR) in a high-risk valve-in-mitral annular calcification case, according to a new case report. Published in JACC: Cardiovascular Interventions, the case centered on a 78-year-old woman with prior transatrial ViMAC using a 26-mm SAPIEN 3 valve and surgical aortic valve replacement performed nine years earlier. She presented with dyspnea and severe bioprosthetic mitral stenosis. Preprocedural computed tomography demonstrated a predicted neo-LVOT area near 0 mm², alongside commissural misalignment toward the medial trigone of the previously implanted valve. A novel technique “Balloon-assisted translocation of the mitral anterior leaflet (BATMAN) is a novel technique to prevent left ventricular outflow tract obstruction (LVOTO) during transcatheter mitral valve replacement,” the authors wrote, led by Chantal Y. Asselin, MD, from the Gagnon Cardiovascular Institute, Atlantic Health System in Morristown, New Jersey. “Its usefulness in redo valve–in–mitral annular calcification (ViMAC) at high risk for LVOTO has not been reported.” The team detailed that in this case, invasive hemodynamics demonstrated a baseline peak-to-peak gradient of 37 mm Hg between the aorta and left ventricle, reinforcing the need for a leaflet modification strategy to enable safe redo intervention. BATMAN begins A transseptal BATMAN procedure was selected and performed, with leaflet traversal near the medial commissure using an electrified guidewire. This was then followed up by sequential balloon dilation and intraleaflet implantation of a 23-mm SAPIEN 3 Ultra RESILIA valve with additional volume. “Redo ViMAC with high risk for LVOTO is a challenging scenario,” the case report’s authors explained. “Leaflet modification with either tip-to-base or base-to-tip LAMPOON may not be feasible, as the frame of the previously implanted S3 may impede leaflet laceration or snaring of the wire used for leaflet traversal.” Invasive post-procedural assessment showed a reduction in peak-to-peak transaortic and LVOT gradient to 26 mm Hg, with no significant residual transmitral gradient, and closure of a residual atrial septal defect with bidirectional shunting using an atrial septal occluder. Follow-up outcomes At 30-day follow-up, the patient was in New York Heart Association functional class I. Further examination of the patient using transthoracic echocardiography showed a mean transmitral gradient of 5 mm Hg and stable transaortic gradients. “In this situation, BATMAN was useful in enabling redo ViMAC despite LVOT commissural misalignment and high risk for LVOTO,” said the case report’s authors. They highlighted that although this approach was limited to a single case, transseptal BATMAN could provide another alternative for carefully selected redo ViMAC patients, where conventional leaflet modification methods are not possible. Source: Asselin CY, Koulogiannis K, Kipperman R, et al. Transseptal BATMAN for Re-Do Valve-in-MAC With Near-Zero Neo-LVOT and Commissural Misalignment. JACC: Cardiovascular Interventions. 2025 February (Article in Press). Image Credit: kieferpix – stock.adobe.com