Transcatheter Mitral Valve Replacement Using the Repositionable LOTUS

Transcatheter Mitral Valve Replacement Using the Repositionable LOTUS valve in a Patient at High Risk of Left Ventricular Outflow Track Obstruction Vivek Rajagopal, MD

Clinical Presentation • 76 y/o woman with severe peripheral vascular disease, left main disease, severe aortic stenosis (mean gradient = 40 mm. Hg) and mitral annular calcification (mean gradient = 16 mm. Hg) with NYHA III symptoms. • Extreme risk for surgery given porcelain aorta Page 2

Baseline Imaging Page 3

Baseline Imaging Page 4

Case Planning • Staged left main stenting and transapical TAVR planned but transcatheter mitral valve replacement (TMVR) was deferred given very high risk of left ventricular outflow tract obstruction (LVOT). Page 5

Coronary Stenting and Transapical TAVR Baseline Angiogram Bifurcation Stenting • Transapical 23 mm Sapien XT Page 6

Persistent NYHA III symptoms • Plan to do prophylactic alcohol septal ablation • Compassionate use of 27 mm Lotus valve in MAC via trans-apical approach to allow for repositioning and even retrieval in the case of an unacceptable LVOT gradient. Page 7

Alcohol Septal Ablation • Page 8

Lotus Valve in MAC Implantation Page 9

Conclusions • Alcohol septal ablation can mitigate risk of LVOT obstruction prior to TMVR. • Implantation of the repositionable Lotus valve in MAC is feasible and might have advantages over a balloon-expandable prosthesis. Page 10