While interest is increasing in transcatheter mitral valve replacement (TMVR) for the growing number of patients with mitral valve disease at high risk for surgery, the risk of left ventricular outflow tract (LVOT) obstruction is a major obstacle and it is a predictor of poor outcome after TMVR. Several emerging treatment strategies have been shown to reduce the risk of LVOT obstruction, according to a state-of-the-art review published April 24 in JACC: Cardiovascular Interventions.

Mackram F. Eleid, MD, FACC, et al., review assessing the risk of LVOT obstruction before TMVR and the impact of the device design on the risk of LVOT obstruction. They also describe novel techniques to pre-emptively reduce the risk, including alcohol septal ablation, radiofrequency septal ablation and anterior leaflet electrosurgical laceration.

The authors also introduce a new algorithm that outlines their approach to prevent LVOT obstruction after TMVR. The so-called neoLVOT management algorithm they propose is being studied in the prospective MITRAL 2 study.

They write, "As experience with LVOT modification techniques in TMVR grows, more data regarding patient selection and efficacy of these approaches will become available." They also note there are several dedicated devices for TMVR under investigation that by their design will "avoid LVOT obstruction by actively securing the anterior leaflet away from the LVOT. It is anticipated that more patients will become candidates for TMVR as these devices become available."

Access an Interactive Central Illustration that accompanies the state-of-the-art review here. Through audio captions, the authors provide additional insight into key findings of the manuscript.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Nuclear Imaging

Keywords: Mitral Valve, Ventricular Outflow Obstruction, Lacerations, Electrosurgery, Heart Valve Diseases, Angiography

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