Unilateral Folding of Anterior Mitral Valve Leaflet (UNIFOLD) For Transcatheter Mitral Valve Replacement: First-in-Human Experience
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J INVASIVE CARDIOL 2025. doi:10.25270/jic/25.00022. Epub February 28, 2025.
The LAMPOON (Laceration of the Anterior Mitral leaflet to Prevent Outflow ObstructioN) technique reduces left ventricular outflow tract (LVOT) obstruction risk from transcatheter mitral valve replacement (TMVR) by lacerating the anterior mitral valve leaflet (AMVL). Here, we propose the Unilateral Folding of AMVL (UNIFOLD) as a novel mechanism to prevent LVOT obstruction.
A 69-year-old man had previously undergone mitral valve repair in 2008 with a 30-mm Carpentier-Edwards Physio II annuloplasty ring (Edwards Lifesciences) and a GORE-TEX artificial chordae (Gore Medical) to the AMVL in 2008. Sixteen years after the procedure, he developed severe mitral regurgitation (MR) with ruptured artificial chordae, flail AMVL, and restrictive posterior mitral valve leaflet (PMVL) (Figure A). His left ventricular ejection fraction was preserved. He had high risk of LVOT obstruction from a long AMVL (37.1 mm). The consensus of the heart team was to attempt repair using NeoChord DS1000 device (NeoChord, Inc.); if results were unsatisfactory, it was decided to perform TMVR with the UNIFOLD technique.
During the operation, satisfactory MR reduction could not be achieved despite successful NeoChord insertion to the A2 (Figure B and C); elective conversion to TMVR was performed. The septum was traversed using VersaCross (Boston Scientific), and the mitral valve was crossed using an Agilis NxT steerable introducer (Abbott) and a pigtail catheter. A SAFARI2 extra small curve (Boston Scientific) was inserted to the apex, and transeptal access was dilated. UNIFOLD was performed by advancing a 7-French dilator via the transapical NeoChord rail to push the AMVL into left atrium, before slowly deploying a 29-mm SAPIEN 3 Ultra RESILIA (Edwards Lifesciences) under rapid pacing (Figures D and F, Video). The dilator was withdrawn after valve deployment, and post-dilatation with the same balloon was performed. Echocardiography confirmed AMVL folding to atrial side without LVOT obstruction (Figure G and H).
In this case, we demonstrated AMVL folding as a novel mechanism for LVOT protection (Figure I-K). Development to enable a transfemoral approach may allow the technique to be widely used.
Affiliations and Disclosures
Simon Cheung-Chi Lam, MBBS1,2; Shu-Yue Sze, MBBS1,2; Chun-Ka Wong, MBBS1,2; Kwong-Yue Eric Chan, MBBS1,2,3; Ka-Chun Un, MBBS MRes1,2; On-Yat Wong, MBBS4; Ming Lau, MBBS5; Ho-On Alston Conrad Chiu, MBBS1,2; Daniel Tai-Leung Chan, MBBS5
From the 1Cardiology Division, Department of 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 Anaesthesia, Queen Mary Hospital, Hong Kong SAR, China; 5Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong SAR, China.
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 interventions described in the manuscript and for the publication thereof.
Address for correspondence: Simon Cheung-Chi Lam, MBBS, Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China. Email: drsimonlam@hotmail.com
