Transcatheter Mitral Valve-in-Valve Replacement With Balloon-Assisted Translocation in Calcified Mitral Anterior Leaflet

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OBJECTIVE: A significant anatomical limitation of transcatheter mitral valve replacement (TMVR) is the risk of left ventricular outflow tract obstruction. Here, we describe balloon-assisted translocation in mitral anterior leaflet (BATMAN) in a patient with a calcified bioprosthetic mitral valve. KEY STEPS: The anterior mitral leaflet is traversed with a 0.014-inch stiff wire with electrocautery, followed by the delivery of a long sheath and placement of dual wires. The dual-wire system allows for BATMAN, followed by a rapid delivery of the transcatheter heart valve, minimizing exposure to significant mitral regurgitation. POTENTIAL PITFALLS: Leaflet traversal with a 0.035-inch system may be difficult because of leaflet calcification, and translocation of the anterior mitral leaflet without dual wires in place potentially exposes the patient to intraprocedural hemodynamic compromise. TAKE-HOME MESSAGES: Transcatheter mitral valve replacement with BATMAN in calcified leaflets may be facilitated by lower-profile crossing wires. Placement of dual wires for rapid exchange following BATMAN may reduce the risk of hemodynamic consequences.

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