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IMAGES IN INTERVENTION

Bail-Out Alcohol Septal Ablation forLeft Ventricular Outflow TractObstruction After TranscatheterMitral Valve Replacement

Pierre Deharo, MD,a Marina Urena, MD,a Dominique Himbert, MD,a Eric Brochet, MD,a Frederic Rouleau, MD,b

Frederic Pinaud, MD, PHD,b Stephane Delepine, MD,b Jose Luis Carrasco, MD,a Walid Ghodbane, MD,a

Fabrice Extramiana, MD,a Phalla Ou, MD, PHD,a Marie Pierre Dilly, MD,a David Messika-Zeitoun, MD, PHD,a

Bernard Iung, MD, PHD,a Patrick Nataf, MD,a Alec Vahanian, MDa

A 76-year-old woman with degenerativemitral valve disease was referred for refrac-tory heart failure. An echocardiogram

showed the presence of a massive mitral annularcalcification with severe stenosis (mitral valve area,1.0 cm2; mean gradient, 11 mm Hg) and a smallleft ventricular cavity with a 23-mm septal bulgewithout obstruction (Figures 1A to 1C, Online Video 1).Computed tomography (CT) findings were almostcircumferential calcification of the mitral annulus;mitral annulus diameter of 22.8 � 30.0 mm and areaof 472 mm2, and mitral annulus-aorta angle of 122�

(Figures 1D to 1F).The heart team recommended a transcatheter

mitral valve replacement (TMVR). The procedure wasperformed via the transseptal approach using a26-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine,California) (Online Video 2). Immediately afterdeployment, the patient had severe hypotensionrequiring hemodynamic support (Figures 2A and 2B).An echocardiographic assessment showed a satisfac-tory function of the prosthesis (trace paravalvular leakand a mean gradient of 5 mm Hg), which contacted theseptum, leading to a severe left ventricular outflow

From the aBichat Claude Bernard Hospital-Paris VII University, Paris, France;

Dr. Himbert is a consultant for Edwards Lifesciences and a proctor for Med

Boehringer Ingelheim and has received speakers fees from Edwards Lifes

Lifesciences. Dr. Vahanian has received speakers fees from Abbott Vascula

Advisory Board of Medtronic. All other authors have reported that they have n

to disclose. Drs. Deharo and Urena contributed equally to this work.

Manuscript received December 21, 2015; accepted January 3, 2016.

tract (LVOT) obstruction with a maximal gradient of100 mm Hg (Online Video 3), confirmed by hemody-namic measurements (Figure 2B). Bail-out septalalcohol ablation was performed (Figures 3A to 3C) withan initial restoration of systemic pressure and amarked decrease in LVOT gradient (Figures 3D and 3E).A few hours later, a permanent pacemaker wasimplanted because of a secondary increase in theLVOT gradient. Thereafter, the evolution was favor-able, and the patient was discharged on day 12. Sixmonths after the procedure, the patient was in NewYork Heart Association functional class II. Echocar-diographic and CT images confirmed an adequateprosthesis placement and function (Online Video 4)and a maximal LVOT gradient of 25 mm Hg.

Severe LVOT obstruction is life-threateningcomplication of TMVR. A septal bulge with a smallleft ventricular cavity increases the risk of thiscomplication. Therefore, left ventricular morphologyshould be carefully evaluated before the procedure,and contraindication to the intervention should beconsidered if such features are observed. If severeLVOT obstruction occurs, bail-out alcohol septalablation may be lifesaving.

and the bAngers University Hospital, Angers, France.

tronic. Dr. Iung is a consultant for Abbott Vascular

ciences. Dr. Nataf is a former proctor for Edwards

r, Edwards Lifesciences, and Valtech; and is on the

o relationships relevant to the contents of this paper

FIGURE 1 Echocardiographic and Computed Tomography Images of the Mitral Valve and Left Ventricle

Three- and 2-dimensional echocardiographic images showing a degenerative mitral valve with massive annular calcification (A), severe mitral stenosis (B), and a

small left ventricular cavity with a septal bulge (C, Online Video 1). Three-dimensional volume-rendered computed tomography image showing roughly circumferential

calcification of the mitral annulus (D); oblique reconstruction and sagittal view showing the dimensions of the mitral annulus and the mitral annulus to aorta angle

(E and F).

Deharo et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 8 , 2 0 1 6

LVOT Obstruction After Transcatheter Mitral Valve Replacement A P R I L 2 5 , 2 0 1 6 : e 7 3 – 6

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FIGURE 2 Doppler Echocardiographic Images and Hemodynamic Curves Showing the Changes in the LVOT Gradient

(A) Before implantation of the prosthesis, the aortic pressure was 111/45 mm Hg, the shape of the aortic pressure wave was normal, and there

was not a significant gradient at the LVOT. (B) Immediately after implantation of the prosthesis, the aortic pressure decreased to 78/45,

the shape of the aortic pressure wave changed to a spike-and-dome pattern, and the maximal LVOT gradient was>100 mm Hg (Online Videos 2

and 3). LV ¼ left ventricle; LVOT ¼ left ventricular outflow tract.

J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 8 , 2 0 1 6 Deharo et al.A P R I L 2 5 , 2 0 1 6 : e 7 3 – 6 LVOT Obstruction After Transcatheter Mitral Valve Replacement

e75

FIGURE 3 Fluoroscopy Images Showing the Different Steps of the Septal Alcohol Ablation Procedure and Hemodynamic Curves and

Echocardiographic Images Showing Acute Results

(A) A coronary angiogram confirmed the presence of a septal artery suitable for alcohol ablation. Two milliliters of pure ethanol were injected in the first septal

branch (B), with complete occlusion of the artery (C, white arrows). (D) Immediately after injecting the ethanol, a normalization of the shape of the aorta pressure curve

and recovery of the pressure were observed. (E) Echocardiographic assessment confirmed the maximal left ventricular outflow gradient of 24 mm Hg (Online Video 4).

LV ¼ left ventricle.

Deharo et al. J A C C : C A R D I O V A S C U L A R I N T E R V E N T I O N S V O L . 9 , N O . 8 , 2 0 1 6

LVOT Obstruction After Transcatheter Mitral Valve Replacement A P R I L 2 5 , 2 0 1 6 : e 7 3 – 6

e76

REPRINT REQUESTS AND CORRESPONDENCE:

Dr. Dominique Himbert, Bichat Claude BernardHospital-Paris VII University, 46 Henri Huchard,75018 Paris, France. E-mail: dominique.himbert@aphp.fr.

KEY WORDS alcohol septal ablation, left ventricular outflow obstruction,mitral annular calcification, transcatheter mitral valve implantation

APPENDIX For supplemental videos, please see the onlineversion of this article.