Antegrade-transseptal approach for left ventricular tachyarrhythmia in patients with previous transcatheter edge-to-edge mitral valve repair

M. Khalaph (Bad Oeynhausen)¹, P. Lucas (Bad Oeynhausen)¹, D. Guckel (Bad Oeynhausen)¹, T. Fink (Bad Oeynhausen)¹, V. Sciacca (Bad Oeynhausen)¹, M. Mörsdorf (Bad Oeynhausen)¹, V. Nesapiragasan (Bad Oeynhausen)¹, M. Braun (Bad Oeynhausen)¹, M. Didenko (Bad Oeynhausen)¹, H. Omran (Bad Oeynhausen)², T. K. Rudolph (Bad Oeynhausen)², V. Rudolph (Bad Oeynhausen)², G. Imnadze (Bad Oeynhausen)¹, C. Sohns (Bad Oeynhausen)¹, M. El Hamriti (Wetzikon)³, P. Sommer (Bad Oeynhausen)^1
1Herz- und Diabeteszentrum NRW Klinik für Elektrophysiologie/ Rhythmologie Bad Oeynhausen, Deutschland; ²Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ³GZO Spital Wetzikon Klinik für Kardiologie und Angiologie Wetzikon, Schweiz

Introduction:
Treatment of patients with ventricular tachyarrhythmia (VT) that previously underwent transcatheter-edge-to-edge repair (TEER) of the mitral valve can be especially challenging. In particular, the antegrade-transseptal approach serves as a practicable approach in these patients and has several benefits compared to the conventional retrograde, transaortic approach.

Objective:
The Aim of this study was to evaluate the feasibility, the clinical outcome and peri- and postprocedural complications in patients who underwent VT ablation after previous TEER. 

Material and Methods: 
All patients with TEER and VT ablation who were treated at our department between 2019 and 2024 were included in this monocentric, retrospective observational study.  All included patients received transcatheter antegrade-transseptal VT ablation. On the first post-procedural day, the position of the mitral valve clip was checked sonographically. 

Results: 
A total of 18 patients (mean age 72±9 years, 83% male) with a history of TEER presented to our clinic due to VT and underwent a VT-ablation. The mean time between TEER and VT ablation was 23.17±19.12 months (range 2 months to 5 years). The mean number of implanted clips on the mitral valve was 1.6±0.7, of which 9 patients had 1 clip on the mitral valve, 7 patients had 2 clips and 2 patients had 3 clips. The mean procedural time was 132.33±25.71 minutes, mean ablation time was 32.2±13.1 minutes, and mean fluoroscopy time was 10.0±3.9 minutes. Catheter manipulation through both septal and lateral opening of mitral valve post TEER was possible in all patients either directly or with a small or large loop regardless of number of clips (Figure 1).  Complete electroanatomic mapping was possible in all patients. No patient showed dislocation of the mitral valve clip on the first post-procedural day. During a mean follow-up period of 34 months three patients experienced VT recurrence. 

Conclusion:
Antegrade transseptal approach for ablation of left VT is feasible and safe in patients with previous TEER of the mitral valve. Complete electroanatomic mapping of the left ventricle was possible in all patients. There was no peri- and post-procedural complications, in particular no dislocation of the clips could be detected.

Figure 1:
Fluoroscopic demonstration how to reach ventricle parts through septal und lateral opening of MV post TEER.