Current Evidence, Emerging Evidence and Decision Making: An Algorithm for Leaflet Modification Procedures (JACC Cardiovascular Interventions June 2026)-Article: Current Evidence, Emerging Evidence and Decision Making: An Algorithm for Leaflet Modification Procedures

Pdf Summary

This state-of-the-art review summarizes current and emerging techniques for leaflet modification in structural heart interventions, especially to prevent coronary obstruction during transcatheter aortic valve replacement (TAVR) and left ventricular outflow tract obstruction (LVOTO) during transcatheter mitral valve replacement (TMVR).<br /><br />The authors reviewed preclinical, animal, registry, and clinical data through February 2026 and used expert consensus to build practical algorithms for choosing among procedures based on anatomy, pathology, and procedural goals. The review groups approaches into two broad categories: leaflet splitting/laceration and intraleaflet deployment. Key established techniques include BASILICA for aortic valves and LAMPOON for mitral valves. Emerging options include UNICORN and BATMAN, while hybrid extraction/resection methods such as SURPLUS and CATHEDRAL are considered in select cases.<br /><br />For aortic interventions, preprocedural CT is central for estimating coronary obstruction risk. Standard BASILICA is recommended for suitable native or valve-in-valve cases, while balloon-augmented BASILICA (BA-BASILICA) or UNICORN may help when leaflet splay may be inadequate or coronary anatomy is extremely high risk. Mechanical BASILICA has a role mainly in TAV-in-SAV cases, but calcified or flail leaflets can limit success.<br /><br />For TMVR, CT is used to predict neo-LVOT and skirt neo-LVOT dimensions. Standard LAMPOON is preferred when traversal and leaflet splay are feasible, but septal reduction therapy (especially alcohol septal ablation or SESAME) may be needed when LVOT obstruction risk remains prohibitive. BA-LAMPOON or BATMAN can be useful when leaflet splay is expected to be insufficient. In valve-in-valve or valve-in-ring cases with protected anatomy, BA-LAMPOON or BATMAN may be reasonable; in valve-in-MAC or vulnerable ring cases, BA-LAMPOON is favored.<br /><br />The review concludes that leaflet modification is now an essential part of structural heart therapy, but evidence remains incomplete, especially for newer intraleaflet methods. Future work should focus on comparative trials, better imaging, dedicated devices, and long-term durability outcomes.

Meta Tag

Concept Leaflet Modification

Concept Coronary Obstruction

Concept Left Ventricular Outflow Tract Obstruction

Concept Transcatheter Aortic Valve Replacement

Concept Transcatheter Mitral Valve Replacement

Keywords

leaflet modification

structural heart interventions

TAVR

TMVR

BASILICA

LAMPOON

coronary obstruction

LVOTO

CT imaging

septal reduction therapy

Leaflet Modification

Coronary Obstruction

Left Ventricular Outflow Tract Obstruction

Transcatheter Aortic Valve Replacement

Transcatheter Mitral Valve Replacement