BATMAN and WOLVERINE: The New Alliance for Valve-in-Mitral Annular Calcification

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/25.00369. Epub December 1, 2025.

A 78-year-old man with symptomatic severe mitral stenosis (Figure 1A) due to extensive mitral annular calcification (MAC) was deemed unsuitable for surgery. Preprocedural computed tomography predicted prohibitive left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve implantation (TMVI), with a predicted neo-LVOT area of 98.2 mm² (Figure 1B).¹ To mitigate LVOT obstruction, anterior mitral leaflet (AML) fenestration using the balloon-assisted translocation of the anterior mitral leaflet (BATMAN) technique was performed.²

After transseptal puncture, a steerable sheath and Judkins Right-4 catheter were positioned toward the A2 scallop of the AML (Figure 1C). A straight 0.035-inch electrified wire successfully traversed the AML into the left ventricle (Figure 1D and E; Video 1). Initial dilations with noncompliant 6- and 7-mm balloons produced marked dogboning, and lithotripsy (120 pulses) with an 8-mm M5 balloon (Shockwave Medical) did not relieve the waist, consistent with a fibrotic rather than calcified AML (Figure 1F and 2A). Therefore, it was decided to proceed with a 4-mm WOLVERINE cutting balloon (Boston Scientific). The balloon was inflated at 20 atm and achieved effective leaflet modification (Figure 2B); this was followed by dilations with 7- and 14-mm balloons (Video 2). Subsequently, a 29-mm Myval transcatheter heart valve (Meril) was implanted (Figure 2C). Final angiography and transesophageal echocardiography confirmed excellent expansion (Figure 2D; Videos 3, 4A and B), no significant paravalvular leak, no LVOT obstruction, and good mitral gradients (Figures 2E and F).

In this valve-in-MAC case, calcium was concentrated in the posterior annulus while AML was rather fibrotic. Consequently, the Shockwave balloon failed, whereas the cutting-balloon BATMAN technique increased leaflet compliance, enabling successful subsequent dilatation and TMVI.

Figure 1. (A) Preprocedural mitral gradients. (B) Computed tomography predicting neo-left ventricular outflow tract obstruction. (C) Three-dimensional transesophageal echocardiography (TEE) showing the Judkins Right-4 catheter (white arrow) pointing at the A2 scallop of the anterior mitral leaflet (AML). (D, E) Electrified wire fenestrating AML. (F) Underexpanded M⁵ balloon (Shockwave Medical).

Figure 2. (A) Transesophageal echocardiography (TEE) view of the underexpanded balloon. (B) Anterior mitral leaflet modification using a 4-mm cutting balloon. (C) Prosthetic valve deployment. (D) Final 3-dimensional TEE. (E, F) Postprocedural gradients.

Mattia Basile, MD^1,2; Alfonso Jurado-Román, MD, PhD^1-3; Ander Regueiro, MD, PhD⁴; Silvia Valbuena, MD¹; Guillermo Galeote Escalera, MD⁵; Borja Rivero-Santana, MD, PhD^1,2; Daniel Tebar, MD^1,2; Santiago Jiménez-Valero, MD^1,2; Raúl Moreno, MD, PhD^1-3; Guillermo Galeote, MD, PhD^1,2

From the ¹Cardiology Department, La Paz University Hospital, Madrid, Spain; ²Fundación de Investigación IdiPAZ, Madrid, Spain; ³Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain; ⁴Department of Cardiology, Hospital Clinic, University of Barcelona, Barcelona, Spain; ⁵Servicio de Cardiología, Hospital Universitario de Toledo, Toledo, Spain.

Dr Basile and Dr Jurado-Román share first authorship. Dr Moreno and Dr Galeote share last authorship.

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 intervention described in the manuscript and for the publication thereof, including any and all images.

Address for correspondence: Alfonso Jurado-Román, MD, PhD, Cardiology Department, La Paz University Hospital, Paseo de la Castellana 261, Madrid 28046, Spain. Email: alfonsojuradoroman@gmail.com; X: @JuradoRomanAl