BATMAN-Assisted Valve-in-Valve TMVR With Planned Hemodynamic Support in Severe Pulmonary Hypertension

Left ventricular outflow tract (LVOT) obstruction is a feared complication of transcatheter mitral valve replacement (TMVR), and balloon-assisted translocation of the mitral anterior leaflet (BATMAN) has emerged as a mitigation strategy. Patients with severe pulmonary hypertension are at risk, as abrupt elimination of mitral regurgitation (MR) can destabilize hemodynamics.

A 78-year-old woman with a degenerated 25-mm surgical bioprosthesis, severe pulmonary hypertension (mean pulmonary artery pressure 65 mm Hg), and reduced cardiac index (1.9 L/min/m²) underwent transseptal BATMAN-assisted valve-in-valve TMVR using a 23-mm SAPIEN 3 Resilia valve with planned intra-aortic balloon pump (IABP) support. A computed tomography-predicted neo-LVOT area of 181 mm² guided anterior leaflet modification. MR was eliminated with a mean transmitral gradient of 1 mm Hg, no LVOT obstruction, and stable periprocedural hemodynamics.

BATMAN enabled successful TMVR despite high-risk anatomy. Prophylactic IABP facilitated hemodynamic stability during the transition from chronic MR physiology. This is among the first reports combining planned mechanical circulatory support with BATMAN-assisted TMVR in severe pulmonary hypertension.

BATMAN-assisted valve-in-valve TMVR with planned IABP support may facilitate safe treatment of selected patients with severe pulmonary hypertension and predicted LVOT obstruction.