Transseptal Balloon-Assisted Translocation of the Mitral Anterior Leaflet (BATMAN) in Mitral Valve-in-Ring Implantation

A 49-year-old man was referred to our institution for symptomatic heart failure. He had history of post-actinic valvular heart disease due to previous Hodgkin’s lymphoma treatment and underwent in 2015 surgical aortic valve replacement with mechanical prosthesis On-X (Artivion), mitral valve annuloplasty with a Carpentier-Edwards Physio II 28-mm ring, and pericardial patch anterior mitral leaflet (AML) extension. Echocardiography showed severe mitral regurgitation and stenosis (mean gradient 13 mm Hg), significant pulmonary hypertension, and right ventricular dysfunction (Figure 1A). Patient was deemed at prohibitive surgical risk for re-do cardiac surgery and was scheduled for transcatheter mitral valve-in-ring implantation. Because of the high risk of left ventricular outflow tract (LVOT) obstruction, an anterior leaflet modification procedure was planned (Figures 1B and 1C). Laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON) was excluded because of the presence of double continuous suture along the free margin of the AML. Therefore, we planned a transseptal balloon-assisted translocation of the mitral anterior leaflet (BATMAN).