Antegrade Approach for Left Ventricular Tachyarrhythmia in Patients with Previous Transcatheter Edge-to-Edge Mitral Valve Repair.

Background: Catheter ablation of left ventricular tachyarrhythmias (LVT) in patients with prior mitral valve transcatheter edge-to-edge repair (MV-TEER) can be challenging. The antegrade (transseptal) approach offers several advantages over the conventional retrograde (transaortic) route. However, real-world data on the efficacy and safety of antegrade approach in MV-TEER are limited.

Objective: To assess the feasibility, safety, and clinical effectiveness of antegrade transseptal catheter ablation for LVT in patients with prior MV-TEER.

Methods: This prospective, multicenter study included patients with drug-refractory ventricular tachycardia (VT) and a history of MV-TEER. All underwent the procedure via a transseptal approach. Mitral valve clip position was assessed on the first post-procedural day using transthoracic echocardiography.

Results: All 34 patients (mean age 70.9±8.7 years, 79% male) underwent VT ablation. The median interval between TEER and VT ablation was 2 years [IQR 2-3.5]. Patients had a median of 2 mitral clips [IQR 1-2]: 44.1% had 1 clip, 50.0% had 2 clips, and 5.9% had 3 clips. Catheter manipulation through both septal and lateral openings of the mitral valve was feasible in all cases, regardless of clip number. Complete left ventricular (LV) mapping was achieved without restrictions. No clip dislocations were detected on the first post-procedural day. During a median follow-up of 32 months [IQR 17.5-48.5], VT recurrence occurred in 4 patients (11.8%).

Conclusion: An antegrade approach for LVT ablation is feasible and safe despite previous MV-TEER. Mapping was not impaired by clip presence, and no periprocedural cardiac complications or clip dislocations were observed.