Transseptal BATMAN Procedure Utilizing a Simplified Technique: "Single Wire Approach for Traversing Tissue" (SWATT)

One of the major issues encountered in patients undergoing evaluation for Transcatheter mitral valve replacement (TMVR) is the risk of Left ventricular outflow tract (LVOT) obstruction. LVOT obstruction is a catastrophic complication of TMVR, the result of displacement of the anterior mitral valve leaflet (AML) toward the interventricular septum. Several strategies to mitigate the risk of LVOT obstruction have been described and include percutaneous laceration of the anterior mitral leaflet (LAMPOON), alcohol septal ablation, trans-atrial leaflet modification (SITRAL) and Balloon Assisted Translocation of Mitral Anterior leaflet to prevent LVOT obstruction (BATMAN). These techniques have certain limitations: procedure complexity for LAMPOON, inconsistent results for alcohol septal ablation, and the need for surgery in SITRAL. While the initial description of BATMAN was through a trans-apical approach, the evolution of a trans-septal approach has improved the utility of this technique. These procedures usually require several steps with multiple wire exchanges, snares, and high energy electrocautery. The complexity of these procedures has hindered their widespread adoption. Herein, we describe a simplified technique called the Single Wire Approach for Traversing Tissue (SWATT) utilized to facilitate a trans-septal BATMAN procedure to traverse the valve leaflets and tissue with minimal exchanges, using the commercially available VERSACROSS transeptal system (Boston Scientific, Natick, MA).