Pub Date : 2025-10-23DOI: 10.1016/j.crmic.2025.100115
Ammar Chapra , Cheikh Abool Maaly , Mohammed Al-Hijji , Mohammed Qintar
Transcatheter extraction of intracardiac masses using the ŌNŌ retrieval system has recently emerged as a promising alternative to surgical excision, which remains the widely adopted management strategy. A 67-year-old female was diagnosed with a mass attached to the posterior mitral leaflet, protruding into the left ventricular outflow tract. A modified ŌNŌ retrieval approach successfully extracted the mass under continuous TEE and fluoroscopic guidance. Post-procedural imaging confirmed complete mass removal with preservation of valvular function. Cytopathology revealed extensive calcifications with a giant cell reaction. This is the second reported MICHIGAN procedure that demonstrates a novel transcatheter intervention based on technical adaptations to optimize mass retrieval while preserving valvular integrity, highlighting the evolving role of transcatheter mass extraction strategies.
{"title":"Transcatheter mass extraction using the ŌNŌ retrieval device used as a global embolic protection device","authors":"Ammar Chapra , Cheikh Abool Maaly , Mohammed Al-Hijji , Mohammed Qintar","doi":"10.1016/j.crmic.2025.100115","DOIUrl":"10.1016/j.crmic.2025.100115","url":null,"abstract":"<div><div>Transcatheter extraction of intracardiac masses using the ŌNŌ retrieval system has recently emerged as a promising alternative to surgical excision, which remains the widely adopted management strategy. A 67-year-old female was diagnosed with a mass attached to the posterior mitral leaflet, protruding into the left ventricular outflow tract. A modified ŌNŌ retrieval approach successfully extracted the mass under continuous TEE and fluoroscopic guidance. Post-procedural imaging confirmed complete mass removal with preservation of valvular function. Cytopathology revealed extensive calcifications with a giant cell reaction. This is the second reported MICHIGAN procedure that demonstrates a novel transcatheter intervention based on technical adaptations to optimize mass retrieval while preserving valvular integrity, highlighting the evolving role of transcatheter mass extraction strategies.</div></div>","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100115"},"PeriodicalIF":0.0,"publicationDate":"2025-10-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145467038","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-13DOI: 10.1016/j.crmic.2025.100114
Michael S. Connolly , Allison B. Hall
The OPN super high-pressure balloon is a safe and effective up-front plaque modification tool that facilitates lesion expansion and optimal stent deployment in tight, calcified coronary stenoses. Here we describe a case series of OPN use with very small diameter balloons (1.5–2.5 mm) in tight stenoses and subsequent larger non-compliant (NC) balloon inflation that expands existing calcium fractures. It is best guided by intracoronary imaging, but may have acceptable safety profile even when imaging catheters will not initially cross. This technique may be efficient and cost-effective in applicable cases, relative to other modification options. It is. This technique appears to be a safe, effective, and technically straightforward method for modifying some tight, reasonably calcified coronary lesions.
{"title":"‘Pre-crack the plaque technique’ using OPN super high-pressure balloons in tight, calcified stenoses: A case series","authors":"Michael S. Connolly , Allison B. Hall","doi":"10.1016/j.crmic.2025.100114","DOIUrl":"10.1016/j.crmic.2025.100114","url":null,"abstract":"<div><div>The OPN super high-pressure balloon is a safe and effective up-front plaque modification tool that facilitates lesion expansion and optimal stent deployment in tight, calcified coronary stenoses. Here we describe a case series of OPN use with very small diameter balloons (1.5–2.5 mm) in tight stenoses and subsequent larger non-compliant (NC) balloon inflation that expands existing calcium fractures. It is best guided by intracoronary imaging, but may have acceptable safety profile even when imaging catheters will not initially cross. This technique may be efficient and cost-effective in applicable cases, relative to other modification options. It is. This technique appears to be a safe, effective, and technically straightforward method for modifying some tight, reasonably calcified coronary lesions.</div></div>","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100114"},"PeriodicalIF":0.0,"publicationDate":"2025-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145363109","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Post-Cardiac Injury Syndrome (PCIS) is a rare inflammatory condition following cardiac interventions like PCI, characterized by pleuritic chest pain, fever, pericardial effusion, and ECG changes. Its pathophysiology involves autoimmune responses or micro-extravasation. Though rare (<0.5 % incidence post-PCI), early recognition and treatment are crucial to prevent complications.
Case presentation
A 69-year-old male with unstable angina underwent an unsuccessful PCI for mid-LAD CTO. Eight hours later, he developed pleuritic chest pain and low-grade fever. ECG showed widespread ST-elevations with PR-segment depression, and echocardiography revealed mild pericardial effusion. Inflammatory markers were elevated, but cardiac troponin I remained negative. Despite no visible extravasation on fluoroscopy, micro-extravasation was suspected. A diagnosis of iatrogenic PCIS was made, and he was treated with high-dose aspirin, leading to symptom resolution by day five.
Conclusions
This case underscores the importance of recognizing PCIS post-PCI, even in the absence of visible extravasation. Early diagnosis through clinical signs, ECG, and inflammatory markers enables prompt treatment with NSAIDs, primarily aspirin. With appropriate management, outcomes are favorable, though monitoring for recurrence and long-term complications like constrictive pericarditis remains essential.
{"title":"Post-Cardiac Injury Syndrome following Percutaneous Coronary Intervention: A rare case report","authors":"Ashok Victor , Panneer Selvam Ganesan , Manikandan Rajendran , Nihal Sheriff","doi":"10.1016/j.crmic.2025.100112","DOIUrl":"10.1016/j.crmic.2025.100112","url":null,"abstract":"<div><h3>Background</h3><div>Post-Cardiac Injury Syndrome (PCIS) is a rare inflammatory condition following cardiac interventions like PCI, characterized by pleuritic chest pain, fever, pericardial effusion, and ECG changes. Its pathophysiology involves autoimmune responses or micro-extravasation. Though rare (<0.5 % incidence post-PCI), early recognition and treatment are crucial to prevent complications.</div></div><div><h3>Case presentation</h3><div>A 69-year-old male with unstable angina underwent an unsuccessful PCI for mid-LAD CTO. Eight hours later, he developed pleuritic chest pain and low-grade fever. ECG showed widespread ST-elevations with PR-segment depression, and echocardiography revealed mild pericardial effusion. Inflammatory markers were elevated, but cardiac troponin I remained negative. Despite no visible extravasation on fluoroscopy, micro-extravasation was suspected. A diagnosis of iatrogenic PCIS was made, and he was treated with high-dose aspirin, leading to symptom resolution by day five.</div></div><div><h3>Conclusions</h3><div>This case underscores the importance of recognizing PCIS post-PCI, even in the absence of visible extravasation. Early diagnosis through clinical signs, ECG, and inflammatory markers enables prompt treatment with NSAIDs, primarily aspirin. With appropriate management, outcomes are favorable, though monitoring for recurrence and long-term complications like constrictive pericarditis remains essential.</div></div>","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100112"},"PeriodicalIF":0.0,"publicationDate":"2025-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145321624","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-10DOI: 10.1016/j.crmic.2025.100113
Miguel Gonzalez Toribio , Johan Antonio De la Rosa Laureano , Jean Paul Fernandez
Central venous catheter malposition can signal a thoracic venous anomaly. We report a 56-year-old man whose LIJ catheter tracked left paramediastinally; on-table venography and CT confirmed an isolated persistent left superior vena cava draining to a dilated coronary sinus. Recognition prevented futile repositioning and permitted safe therapy. While CT/MR delineate anatomy, bedside transthoracic echocardiography, specifically adding the suprasternal notch view, with optional left-arm agitated saline, usually suffices to screen for LSVC and related variants. Operators should suspect LSVC when a left-sided catheter fails to cross midline and use targeted imaging to guide management.
{"title":"Left-sided superior vena cava mimicking catheter malposition","authors":"Miguel Gonzalez Toribio , Johan Antonio De la Rosa Laureano , Jean Paul Fernandez","doi":"10.1016/j.crmic.2025.100113","DOIUrl":"10.1016/j.crmic.2025.100113","url":null,"abstract":"<div><div>Central venous catheter malposition can signal a thoracic venous anomaly. We report a 56-year-old man whose LIJ catheter tracked left paramediastinally; on-table venography and CT confirmed an isolated persistent left superior vena cava draining to a dilated coronary sinus. Recognition prevented futile repositioning and permitted safe therapy. While CT/MR delineate anatomy, bedside transthoracic echocardiography, specifically adding the suprasternal notch view, with optional left-arm agitated saline, usually suffices to screen for LSVC and related variants. Operators should suspect LSVC when a left-sided catheter fails to cross midline and use targeted imaging to guide management.</div></div>","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100113"},"PeriodicalIF":0.0,"publicationDate":"2025-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145321625","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-10-03DOI: 10.1016/j.crmic.2025.100109
Nail Kahraman , Nöfel Ahmet Binicier , Deniz Demir
A 67-year-old female patient with a history of mechanical mitral and aortic valve replacement developed Enterococcus faecalis Prosthetic valve endocarditis (PVE). In this patient, who had negative serial blood cultures and had completed an eight-week course of intravenous antibiotic therapy with discharge planned, acute pulmonary edema developed unexpectedly. Transesophageal Echocardiography (TEE), Cinefluoroscopy, and intraoperative findings revealed complete detachment of the posterior mitral annulus, severe paravalvular regurgitation, and pronounced rocking motion of the prosthetic mitral valve. Additionally, moderate-to-severe functional tricuspid regurgitation was identified. An urgent mitral valve replacement using a bioprosthesis was performed in conjunction with tricuspid valve repair. The postoperative recovery was uneventful. Complete posterior annular detachment of the prosthetic mitral valve and pronounced rocking motion following prosthetic mitral valve endocarditis is an extremely rare mechanical complication. These complications, which are rarely observed after mitral PVE, may lead to acute heart failure and circulatory collapse and pose life-threatening risks. We report a rare case of successful revision surgery in a patient who developed paravalvular leak (PVL), posterior annular detachment, and rocking motion of a prosthetic mitral valve following infective endocarditis caused by Enterococcus faecalis.
{"title":"Reoperation for complete posterior annular detachment and rocking motion of a prosthetic mitral valve after infective endocarditis","authors":"Nail Kahraman , Nöfel Ahmet Binicier , Deniz Demir","doi":"10.1016/j.crmic.2025.100109","DOIUrl":"10.1016/j.crmic.2025.100109","url":null,"abstract":"<div><div>A 67-year-old female patient with a history of mechanical mitral and aortic valve replacement developed <em>Enterococcus faecalis</em> Prosthetic valve endocarditis (PVE). In this patient, who had negative serial blood cultures and had completed an eight-week course of intravenous antibiotic therapy with discharge planned, acute pulmonary edema developed unexpectedly. Transesophageal Echocardiography (TEE), Cinefluoroscopy, and intraoperative findings revealed complete detachment of the posterior mitral annulus, severe paravalvular regurgitation, and pronounced rocking motion of the prosthetic mitral valve. Additionally, moderate-to-severe functional tricuspid regurgitation was identified. An urgent mitral valve replacement using a bioprosthesis was performed in conjunction with tricuspid valve repair. The postoperative recovery was uneventful. Complete posterior annular detachment of the prosthetic mitral valve and pronounced rocking motion following prosthetic mitral valve endocarditis is an extremely rare mechanical complication. These complications, which are rarely observed after mitral PVE, may lead to acute heart failure and circulatory collapse and pose life-threatening risks. We report a rare case of successful revision surgery in a patient who developed paravalvular leak (PVL), posterior annular detachment, and rocking motion of a prosthetic mitral valve following infective endocarditis caused by <em>Enterococcus faecalis</em>.</div></div>","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100109"},"PeriodicalIF":0.0,"publicationDate":"2025-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145269896","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Iatrogenic aortocoronary dissection is a rare but life-threatening complication during coronary angiography or percutaneous coronary intervention. We report two cases illustrating distinct clinical outcomes. The first case involved a right coronary artery dissection managed conservatively, followed by successful delayed stenting. The second case involved extensive dissection of the left main coronary artery, leading to vessel occlusion and fatal cardiac arrest despite emergent intervention. These cases highlight the critical importance of early recognition, careful procedural technique, and individualized management strategies. They also emphasize the need for strict adherence to guideline-directed decision-making to optimize patient safety and outcomes in complex coronary interventions.
{"title":"Clinical insights into iatrogenic aortocoronary dissection: a case series of conservative and fatal outcomes","authors":"Saroj Kumar Sahoo, Sai Karthik Kowtarapu, Ramachandra Barik, Dibya Sundar Mahanta, Debasis Acharya, Sindhu Rao Malla, Debasis Panda, Prabhat Kumar Singh","doi":"10.1016/j.crmic.2025.100110","DOIUrl":"10.1016/j.crmic.2025.100110","url":null,"abstract":"<div><div>Iatrogenic aortocoronary dissection is a rare but life-threatening complication during coronary angiography or percutaneous coronary intervention. We report two cases illustrating distinct clinical outcomes. The first case involved a right coronary artery dissection managed conservatively, followed by successful delayed stenting. The second case involved extensive dissection of the left main coronary artery, leading to vessel occlusion and fatal cardiac arrest despite emergent intervention. These cases highlight the critical importance of early recognition, careful procedural technique, and individualized management strategies. They also emphasize the need for strict adherence to guideline-directed decision-making to optimize patient safety and outcomes in complex coronary interventions.</div></div>","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100110"},"PeriodicalIF":0.0,"publicationDate":"2025-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145269895","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-09-19DOI: 10.1016/j.crmic.2025.100108
Huseyin Kandemir , Mustafa Karakurt , Selcuk Ozturk
Spontaneous coronary artery dissection (SCAD) is a rare, non-atherosclerotic cause of acute coronary syndrome, with left main coronary artery (LMCA) involvement being particularly uncommon and life-threatening. We report the case of a 39-year-old previously healthy female who presented with recurrent chest pain and syncope. Initial investigations were inconclusive, but she later developed hypotension and ischemic electrocardiography changes, prompting emergent coronary angiography. A dissection of the LMCA extending into the left anterior descending artery and first diagonal artery was identified, with likely circumflex artery occlusion. Given the patient's instability, immediate percutaneous coronary intervention was performed using a stepwise bifurcation stenting approach, culminating in the culotte technique. The patient made a full recovery with normalization of cardiac function and remained asymptomatic during long-term follow-up. This case highlights the clinical challenges of diagnosing and managing SCAD involving the LMCA and demonstrates that timely intervention with structured bifurcation strategies can result in excellent outcomes, even in high-risk scenarios.
{"title":"Stepwise bifurcation strategy in totally occluded spontaneous left main coronary artery (LMCA) dissection: Successful management with the culotte technique","authors":"Huseyin Kandemir , Mustafa Karakurt , Selcuk Ozturk","doi":"10.1016/j.crmic.2025.100108","DOIUrl":"10.1016/j.crmic.2025.100108","url":null,"abstract":"<div><div>Spontaneous coronary artery dissection (SCAD) is a rare, non-atherosclerotic cause of acute coronary syndrome, with left main coronary artery (LMCA) involvement being particularly uncommon and life-threatening. We report the case of a 39-year-old previously healthy female who presented with recurrent chest pain and syncope. Initial investigations were inconclusive, but she later developed hypotension and ischemic electrocardiography changes, prompting emergent coronary angiography. A dissection of the LMCA extending into the left anterior descending artery and first diagonal artery was identified, with likely circumflex artery occlusion. Given the patient's instability, immediate percutaneous coronary intervention was performed using a stepwise bifurcation stenting approach, culminating in the culotte technique. The patient made a full recovery with normalization of cardiac function and remained asymptomatic during long-term follow-up. This case highlights the clinical challenges of diagnosing and managing SCAD involving the LMCA and demonstrates that timely intervention with structured bifurcation strategies can result in excellent outcomes, even in high-risk scenarios.</div></div>","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100108"},"PeriodicalIF":0.0,"publicationDate":"2025-09-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145160046","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<div><h3>Introduction</h3><div>Left ventricular outflow tract (LVOT) obstruction is a serious complication during transcatheter mitral valve implantation (TMVI) for different indications including in patients with prior mitral bioprosthetic valve replacement. Our case introduces a novel hybrid approach using <strong>b</strong>alloon-assisted <strong>l</strong>aceration <strong>a</strong>nd <strong>s</strong>naring <strong>t</strong>echnique (<strong>BLAST</strong>) of the anterior mitral leaflet (AML) to prevent LVOT obstruction in a high-risk patient with bioprosthetic valve dysfunction.</div></div><div><h3>Case presentation</h3><div>A 79-year-old woman with a history of hypertension, heart Failure with preserved ejection fraction (HFpEF), atrial fibrillation (on warfarin), mitral bioprosthetic valve replacement with 29 mm Mosaic valve in 2013 for severe rheumatic mitral stenosis and TAVR (transcatheter aortic valve replacement) for severe aortic stenosis (AS), presented with severe decompensated heart failure. Echo showed severe bioprosthetic dysfunction with mitral regurgitation (MR) due to flail bioprosthetic leaflet and perforation of the neoanterior leaflet. The patient was treated with multiple vasopressors and diuretics for stabilization prior to being transferred for TMVI as she was deemed prohibitive risk for surgery.</div><div>Preprocedural CT imaging predicted neoLVOT area of 133 mm<sup>2</sup> raising concerns for LVOT obstruction during valve implantation. The predicted LVOT after leaflet modification was 219 mm<sup>2</sup>. Given the complexity of the case, to avoid possible LVOT obstruction, the decision was made to perform a balloon-assisted laceration and snaring of the neoanterior mitral leaflet. After proposed BLAST procedure through a trans-septal approach, a successful TMVI was performed. The peak LVOT gradient post procedure was 9 mmHg. Our patient was stable post-procedure, weaned from vasopressors, and showed significant hemodynamic and clinical improvement in the hospital and at short-term clinic follow-up.</div></div><div><h3>Discussion</h3><div>LVOT obstruction is a well-known challenge in TMVI, in patients with prior mitral valve replacement, annuloplasty or significant annular calcification. Techniques like LAMPOON have been used to prevent LVOT obstruction, but in complex cases, additional strategies may be necessary. The balloon-assisted laceration and snaring technique (proposed acronym <strong>BLAST</strong>) provides an effective and controlled method to address neoanterior leaflet dynamics. This modification may reduce procedural complexity and improve outcomes by ensuring that the LVOT remains unobstructed during valve deployment. This technique could complement or serve as an alternative to LAMPOON, particularly in redo TMVI cases.</div></div><div><h3>Conclusion</h3><div>The <strong>BLAST</strong> procedure demonstrates a promising approach for patients at high risk of LVOT obstruction during TMVI. Further st
{"title":"Balloon-assisted laceration and snaring technique (BLAST) of the anterior mitral leaflet to prevent LVOT obstruction during transcatheter mitral valve implantation: A novel leaflet modification technique","authors":"Khagendra Dahal , Talhat Azemi , Bryan Piccirillo , Sean McMahon , Sheelah Pousatis , Jawad Haider","doi":"10.1016/j.crmic.2025.100101","DOIUrl":"10.1016/j.crmic.2025.100101","url":null,"abstract":"<div><h3>Introduction</h3><div>Left ventricular outflow tract (LVOT) obstruction is a serious complication during transcatheter mitral valve implantation (TMVI) for different indications including in patients with prior mitral bioprosthetic valve replacement. Our case introduces a novel hybrid approach using <strong>b</strong>alloon-assisted <strong>l</strong>aceration <strong>a</strong>nd <strong>s</strong>naring <strong>t</strong>echnique (<strong>BLAST</strong>) of the anterior mitral leaflet (AML) to prevent LVOT obstruction in a high-risk patient with bioprosthetic valve dysfunction.</div></div><div><h3>Case presentation</h3><div>A 79-year-old woman with a history of hypertension, heart Failure with preserved ejection fraction (HFpEF), atrial fibrillation (on warfarin), mitral bioprosthetic valve replacement with 29 mm Mosaic valve in 2013 for severe rheumatic mitral stenosis and TAVR (transcatheter aortic valve replacement) for severe aortic stenosis (AS), presented with severe decompensated heart failure. Echo showed severe bioprosthetic dysfunction with mitral regurgitation (MR) due to flail bioprosthetic leaflet and perforation of the neoanterior leaflet. The patient was treated with multiple vasopressors and diuretics for stabilization prior to being transferred for TMVI as she was deemed prohibitive risk for surgery.</div><div>Preprocedural CT imaging predicted neoLVOT area of 133 mm<sup>2</sup> raising concerns for LVOT obstruction during valve implantation. The predicted LVOT after leaflet modification was 219 mm<sup>2</sup>. Given the complexity of the case, to avoid possible LVOT obstruction, the decision was made to perform a balloon-assisted laceration and snaring of the neoanterior mitral leaflet. After proposed BLAST procedure through a trans-septal approach, a successful TMVI was performed. The peak LVOT gradient post procedure was 9 mmHg. Our patient was stable post-procedure, weaned from vasopressors, and showed significant hemodynamic and clinical improvement in the hospital and at short-term clinic follow-up.</div></div><div><h3>Discussion</h3><div>LVOT obstruction is a well-known challenge in TMVI, in patients with prior mitral valve replacement, annuloplasty or significant annular calcification. Techniques like LAMPOON have been used to prevent LVOT obstruction, but in complex cases, additional strategies may be necessary. The balloon-assisted laceration and snaring technique (proposed acronym <strong>BLAST</strong>) provides an effective and controlled method to address neoanterior leaflet dynamics. This modification may reduce procedural complexity and improve outcomes by ensuring that the LVOT remains unobstructed during valve deployment. This technique could complement or serve as an alternative to LAMPOON, particularly in redo TMVI cases.</div></div><div><h3>Conclusion</h3><div>The <strong>BLAST</strong> procedure demonstrates a promising approach for patients at high risk of LVOT obstruction during TMVI. Further st","PeriodicalId":100217,"journal":{"name":"Cardiovascular Revascularization Medicine: Interesting Cases","volume":"10 ","pages":"Article 100101"},"PeriodicalIF":0.0,"publicationDate":"2025-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145108865","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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