Annular Reduction by Cinching With TEER in Commissure in Conventionally Inappropriate Ring for Transcatheter Valve

Annular reduction by cinching with transcatheter edge-to-edge repair in commissure has been described to enable valve-in-mitral annular calcification. We applied this technique to a patient with an annuloplasty ring too large to allow for treatment with available transcatheter heart valves.

The key steps included the following: Gated computed tomography for measurement of annuloplasty ring, anterior mitral leaflet, and estimated neo-left ventricular outflow tract (LVOT). Transseptal left atrial access is obtained. Mitral transcatheter edge to edge repair (MTEER) is performed with preference for A3-P3 implant. Adjunctive antegrade base-to-tip laceration of the anterior mitral valve leaflet to prevent LVOT obstruction is performed if indicated. Transcatheter heart valve (THV) delivery and deployment.

The potential pitfalls included the following: Medial deployment of the MTEER device is preferred due to the tendency of the THV to engage the lateral mitral anulus during advancement. Assessment of the neo-LVOT must consider the left ventricular septum and the anterior mitral leaflet. The degree of annular change after MTEER is unknown.

In the setting of a mitral annuloplasty ring larger than commercially available THVs, annular reduction by cinching with TEER in commissure in conventionally inappropriate ring for transcatheter valve may be a viable option for enabling transcatheter mitral valve replacement.