Zoe Berg

A team of Yale cardiologists and cardiac surgeons at the Yale New Haven Hospital led by Amit Vora, Samuel Reinhardt ’10, John Forrest MED ’05 and Prashanth Vallabhajosyula ’98 GRD ’98 MED ’02 recently became the first to perform the BATMAN procedure in Connecticut. 

The BATMAN — Balloon-Assisted Translocation of the Mitral ANterior leaflet — procedure is an innovative form of transcatheter mitral valve replacement, or TMVR, a minimally invasive operation that replaces the mitral valve in patients by threading a thin catheter through a blood vessel to get to the heart. 

“It’s only been in the last year or two that people have done what’s called a transseptal procedure, where basically we come up from the vein in the leg, and we start out on the right side of the heart,” Vora told the News. “We use a needle to cross over to the left side of the heart, and then that allows us to do everything from sort of a fully percutaneous approach, where at the end of the day, the patient only has a couple of needle sticks coming from the groin.”

Vora, one of the two interventional cardiologists on the team, led this transcatheter-based approach by carefully directing the catheter throughout the operation. 

Even though TMVR has been widely performed worldwide over the past decade, the procedure’s narrow set of anatomical requirements has inspired the creation of new variations that allow mitral valve replacement in a larger group of patients with mitral valve abnormalities. One of these variations — known as the BATMAN procedure — treats patients with leaking of the mitral valve, known as mitral regurgitation, or MR, specifically in cases where challenging patient anatomy prevents the implementation of standard TMVR. 

In these patients, the heart valve replacement could cause the leaflets of the mitral valve to obstruct blood flow through the left ventricle of the heart, making operating highly risky. In the BATMAN procedure, a small hole is created in the leaflet to insert the valve and prevent obstruction of blood flow. 

One of the keys to safely and effectively mitigating the risks presented by patients undergoing the BATMAN procedure is extensive preparation. Patients undergo numerous preoperative tests to create a three-dimensional map of the heart that allows those performing the procedure to meticulously plan each step in advance. 

During the procedure, a combination of X-ray and ultrasound imaging techniques are used to monitor the heart. A continuous X-ray known as a fluoroscopy helps provide constant images of the heart. But, since not all valve structures show up on an X-ray, a transesophageal echocardiogram is also conducted by placing an ultrasound probe in the esophagus to fill in the gaps on the X-ray. 

Reinhardt, the team’s cardiac imaging specialist, analyzed the data from these real-time pictures to guide Vora’s maneuvers. 

“There’s a lot of constant communication between the imager and the interventionists to decide where we need to go, what moves need to be done to get the catheters where they need to be, and when it’s safe to cut,” Reinhardt said. 

On top of constant communication, the success of the BATMAN procedure heavily relies on an integrated multidisciplinary heart team approach. Vora emphasized that interventional cardiologists, cardiac surgeons, imaging specialists, anesthesiologists, radiologists and nurse coordinators all worked together throughout the procedure to ensure personalized treatment. 

Looking to the future, the Yale team’s success opens the doors for a broader group of patients in the greater Connecticut area affected by MR to receive minimally invasive treatment options that avoid the risks of open heart surgery.

“To have a technique that can offer a transcatheter solution to the type of patient with mitral valve disease where open operations are too high risk is a huge advantage,” Vallabhajosyula, the team’s cardiac surgeon partner, said. 

The transcatheter heart valve system used in TMVR was initially approved by the FDA in 2015.