Anterior mitral leaflet modification with endoscopic scissors during Tendyne implantation

A 73-year-old woman presented with severe mitral regurgitation and New York Heart Association (NYHA) Class IV symptoms. The patient was discussed in our Heart Team and deemed inoperable due to frailty and high surgical risk (Society of Thoracic Surgeons [STS] score: 15.1%). Transoesophageal echocardiography (TOE) showed severe mitral valve regurgitation with a diminutive posterior mitral valve leaflet and consecutive restricted leaflet motion (Moving image 1). An edge-to-edge repair was therefore not considered, but analysis of a full cardiac cycle by computed tomography depicted suitability for Tendyne (Abbott) implantation. Computational modelling revealed a high risk of left ventricular outflow tract obstruction (LVOTO) due to the excessive length (2.8 cm) of the anterior mitral valve leaflet (AML) and small LVOT dimensions (Figure 1A, Moving image 2). In the past, patients with a very tethered, floppy or long AML have been deemed unsuitable for Tendyne implantation: the covered prosthesis holds the native leaflets open during the whole cardiac cycle, and during early systolic outflow, the aforementioned, high-risk AML features can contribute to a “parachute configuration” of the native leaflet with...