A novel technique to reduce left ventricular outflow tract (LVOT) obstruction during transcatheter mitral valve replacement (TMVR) has been shown to be safe and effective, and to result in shorter procedure times. This is according to new data from an international registry presented by Gennaro Giustino (Morristown Medical Center, Morristown, USA) at the 2025 Society for Cardiovascular Angiography & Interventions (SCAI) scientific sessions (1–3 May, Washington, DC, USA).
Balloon-assisted anterior mitral leaflet modification, known as the BATMAN technique, involves deploying the transcatheter mitral valve within the anterior mitral valve leaflet. It is intended to prevent LVOT obstruction—which is associated with mortality and screen failure for TMVR—by causing posterior translocation of the anterior leaflet tip and chords, mimicking surgical posterior translocation during mitral valve replacement.
Current strategies to prevent LVOT obstruction include percutaneous laceration of the anterior mitral leaflet, or LAMPOON, which operators say has a steep learning curve, is technically challenging and is time consuming.
To date there have been no studies to demonstrate the safety and efficacy of the BATMAN procedure, prompting the current analysis. The study included 41 patients at high risk of LVOT obstruction undergoing transseptal TMVR with balloon-assisted anterior mitral leaflet modification across 12 structural heart centres in the USA, Canada, and Europe.
The primary efficacy endpoint was the rate of successful TMVR with freedom from LVOT obstruction (LVOT mean gradient >50 mmHg) and no procedural death. The primary safety endpoint was the in-hospital composite of death, stroke, or major cardiac structural complications according to the mitral valvular academic consortium (MVARC) criteria.
Giustino reported that the primary efficacy endpoint was met in 92.7% of patients. Leaflet traversal and balloon laceration were successful in all cases, and there were no cases of residual LVOT obstruction.
The median time between leaflet traversal and valve implantation was only 28 minutes. The primary safety endpoint occurred in 9.8% of patients due to two deaths in the valve in mitral annular calcification group and one death in the valve-in-valve group. There were no primary safety events in the valve-in-ring group. There were no cardiac structural complications attributed to the technique, and no cases of stroke.
“Traditionally, the LAMPOON technique and its various iterations has been used to enable TMVR in patients at high risk of LVOT obstruction; however, this technique has a steep learning curve and is technically more challenging and time-consuming,” said Giustino, the lead author of the study. “The findings from this study highlight that BATMAN may be considered as an alternative to LAMPOON associated with excellent efficacy and safety, particularly for valve-in-ring and valve-in-valve procedures, providing another option for physicians.”
