Transient Hemolysis Following Transcatheter Mitral Valve Replacement With a Simplified BATMAN Technique

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/25.00037. Epub February 21, 2025.

A 74-year-old woman with previous mitral valve repair (30-mm Carpentier-Edwards Physio II annuloplasty ring) developed severe mitral regurgitation. Long anterior mitral leaflet (28.7 mm) conferred high risk of left ventricular outflow tract (LVOT) obstruction. Transcatheter mitral valve replacement (TMVR) with a simplified “Balloon Assisted Translocation of the Mitral Anterior Leaflet to Prevent Left Ventricular Outflow Obstruction” (BATMAN) technique was performed.

An intra-aortic balloon pump was preemptively used. A VersaCross (Boston Scientific) traversed the septum and A2 base (Figure A-C). A2 fenestration was dilated with 3- and 14-mm balloons; the 14-mm balloon then dilated the septum (Figure D and E). A provisional approach was adopted, and a buddy wire would only be inserted if needed. The A2 fenestration was traversed easily with a 29-mm SAPIEN 3 (Edwards LifeSciences) without buddy wire and was deployed. The final LVOT gradient was 7/4 mm Hg.

On postoperative day 1, intravascular hemolysis occurred with hemoglobinuria, anemia, elevated indirect bilirubin, and lactate dehydrogenase (Figure 1I). Blood film showed polychromasia and red cell fragmentation, suggesting microangiopathic hemolytic anemia (Figure 1J). Anti-globulin and anti-ADAMTS13 were negative, and transesophageal echocardiography confirmed only trivial paravalvular leak. The patient’s blood pressure increased significantly after TMVR, so vasodilators were initiated to reduce the afterload. Clopidogrel, initiated shortly before TMVR, was discontinued, as drug-induced hemolysis could not be ruled-out. The hemolysis improved and biochemistry normalized in 2 weeks.

We introduced a simplified BATMAN workflow using a VersaCross and a 14-mm balloon for both septum and A2 fenestration. We also outlined an approach to post-TMVR hemolysis, which affects about 7.1% of valve-in-ring TMVR cases. Although usually self-limiting, hemolysis can cause renal injury or require reintervention. Mechanisms include paravalvular leaks, LVOT turbulence, and, in rare cases, drug-induced hemolysis.¹

Affiliations and Disclosures

Kwong-Yue Eric Chan, MBBS^1,2,3; Daniel Tai-Leung Chan, MBBS⁴; Simon Cheung-Chi Lam, MBBS^1,2; Michael Shu-Yue Sze, MBBS^1,2; Ka-Chun Un, MBBS MRes(Med)^1,2; Yui-Ming Lam, MBBS^1,2; Ricky Wang-Hei Leung, MBBS^1,2; Jamilla Li, MBBS⁵; Helen Wong, MBBS⁵; Harinder Gill, MBBS, MD⁶; Chun-Ka Wong, MBBS^1,2

From the ¹Cardiology Division, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China; ²Cardiology Division, Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China; ³Cardiac Medical Unit, Grantham Hospital, Hong Kong SAR, China; ⁴Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, China; ⁵Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China; ⁶Division of Haematology, Haematological Oncology and Haemopoietic Stem Cell Transplantation, Department of Medicine, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.

Dr K-Y Chan, Dr D Chan, and Dr Lam are co-first authors.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and for the publication of thereof.

Address for correspondence: Chun-Ka Wong, MBBS, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China. Email: wongeck@hku.hk

Reference

1. El-Sabawi B, McCabe JM, Whisenant B, et al. Hemolysis after transcatheter mitral valve replacement in degenerated bioprostheses, annuloplasty rings, and mitral annular calcification: incidence, patient characteristics, and clinical outcomes. Catheter Cardiovasc Interv. 2021;98(4):776-785. doi:10.1002/ccd.29738