nhlbi dir lampoon study: intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction during transcatheter mitral valve implantation

Conditions: Mitral Valve Failure

Summary: background: transcatheter mitral valve replacement (tmvr) is recommended for some people with mitral valve heart problems. but the usual tmvr techniques might cause an obstruction for some people. a new technique is called lampoon. it may have less risk of obstruction. participants in this study will be among the first in the world to have this technique done. objectives: to test the safety and effectiveness of the lampoon technique in tmvr. eligibility: adults ages 21 and over who are recommended to have tmvr with lampoon design: participants will be screened with medical history and exam and by review of medical records. participants will have blood tests, an ecg, a heart ct scan, and an echocardiogram before the procedure. participants will have tmvr with lampoon. they will have anesthesia or moderate sedation for the procedure. doctors will use a wire to split the diseased mitral valve and move it out of the way before inserting the artificial mitral valve. participants will recover in an inpatient recovery unit. they will repeat the previous tests before leaving the hospital, 1 month later, 6 months later and 1 year later. they will have yearly follow-up phone calls for about 5 years. in the event of a participant's death, researchers will ask for an autopsy and to analyze the heart. permission for this is not required as part of the study.

transcatheter mitral valve replacement (tmvr) is an option to treat mitral valve failure when no surgical options exist. in as many as half of patients, tmvr can cause life-threatening blockage of the left ventricle by displacing the existing mitral valve leaflet. for these patients the only options appear to avoid tmvr or in some to cause a focused heart attack and to wait 6 weeks. the investigators have developed and tested a technique to split the existing mitral valve leaflet and enable tmvr in patients who have no other options. the procedure is called intentional laceration of the anterior mitral leaflet to prevent left ventricular outflow tract obstruction (lampoon). although there are no dedicated tmvr devices commercially available, there has been short-term success with implanted transcatheter aortic valve devices in the mitral position for tmvr. the purpose of this study is to perform lampoon and tmvr in patients who have no good options to treat their mitral valve failure, using heart valve devices designed to implant in the aortic valve position.

Eligibility criteria:
inclusion criteria: * adults age greater than or equal to 21 years * severe symptomatic native mitral valve failure after mitral annuloplasty repair or related to mitral annular calcification. * unacceptably high or prohibitive risk for surgical mitral valve replacement and indicated for transcatheter mitral valve replacement (tmvr) as determined by the multidisciplinary institutional heart team, including at least one cardiovascular surgeon who has examined the patient. * high or prohibitive risk of lvot obstruction (predicted neo-lvot less than 200 mm2) or transcatheter heart valve dysfunction from long/redundant anterior mitral valve leaflet, as determined by the multidisciplinary institutional heart team. * anatomic eligibility for lampoon based on core lab assessment of the baseline ct and echocardiogram. * concordance of the study selection team exclusion criteria * subjects unable to consent to participate, unless the subject has a legally authorized representative * subjects unwilling to participate or unwilling to return for study follow-up activities. * predicted neo-lvot created by the sapien-3 skirt, after lampoon, less than 150 mm2 * tavr within 6 weeks * intended concurrent structural heart procedure, such as aortic or tricuspid valve implantation * pregnancy or intent to become pregnant prior to completion of all protocol follow-up procedures

Keywords: lvot (left ventricular outflow tract, obstruction) transcatheter mitral valve implantation transcatheter heart valve mitral valve regurgitation mitral valve stenosis