When Anatomy Says No: Redefining Mitral Valve Intervention at Atlantic Health Morristown Medical Center

November 2, 2026
Gennaro Giustino, MD

For patients with severe mitral valve disease who have previously undergone surgical repair, the recurrence of mitral regurgitation can present complex clinical crossroads. Redo surgery may carry significant risk, comorbidities may limit options, and transcatheter approaches may be constrained by anatomy altered by prior repair techniques. 

At Atlantic Health Morristown Medical Center, these cases are approached with a focus on expanding therapeutic options through advanced structural heart strategies. 

Gennaro Giustino, MD, structural interventional cardiologist at Atlantic Health, concentrates on complex structural heart interventions across mitral, tricuspid, aortic, and adult congenital disease. 

“We have been expanding the armamentarium of therapies offered to our patients,” Dr. Giustino explains. “I focus on complex structural heart interventions, particularly in patients with challenging anatomy or prior surgical repair.” 

Transcatheter Electrosurgery as a Foundational Tool 

A central capability in these complex cases is transcatheter electrosurgery. 

“Transcatheter electrosurgery is a family of techniques through which we can electrify our tool percutaneously inside the chest,” Dr. Giustino says. “We can perform tissue modification, tissue traversal, or tissue laceration inside of the heart.” 

In the mitral position, this technology enables controlled leaflet modification when anatomy increases concern for left ventricular outflow tract obstruction during transcatheter mitral valve replacement. 

“The LAMPOON procedure is one of them,” he explains. “It consists in the transcatheter laceration of the anterior mitral leaflet to prevent obstruction of the outflow tract.” 

In appropriately selected patients, this strategy allows modification of anatomy that might otherwise exclude transcatheter therapy. 

A Post-Surgical Case Illustration 

Dr. Giustino describes a patient who had undergone robotic mitral valve repair and later presented “very sick with severe mitral regurgitation and pulmonary hypertension,” and was “deemed inoperable for a redo mitral valve surgery.” 

The referral question was whether a transcatheter valve could be placed within the existing mitral ring. 

“The challenge was a prior Alfieri stitch and a long anterior leaflet that would have obstructed the outflow tract,” Dr. Giustino says. 

Using transcatheter electrosurgery, he performed what he describes as “a combined LAMPOON” along with laceration of the Alfieri stitch, enabling safe valve deployment. 

In high-risk physiology, planning must extend beyond anatomy alone. “Sometimes these patients are very sick,” he notes. “They are at risk of getting very sick during the case.” 

In this case, the team initiated “preemptive ECMO,” placing the patient on extracorporeal support before leaflet modification. 

“Using mechanical support proactively allows us to manage extreme-risk anatomy more safely,” he explains. 

The patient was decannulated within days and remained well at follow-up. 

The Role of Experience in Complex Mitral Intervention 

Leaflet modification procedures are a subset of structural heart interventions. At Atlantic Health Morristown, however, the program performs between 30 and 40 leaflet modification procedures annually across the aortic, mitral, and tricuspid valves. 

“This type of complex case really should be treated only at high-volume structural heart disease centers,” Dr. Giustino emphasizes. 

High-volume programs develop coordinated expertise among interventional cardiology, cardiac surgery, advanced imaging, anesthesia, and heart failure teams. For referring physicians, this translates into an environment prepared to anticipate anatomical complexity and procedural instability. 

When to Consider Referral 

Early structural evaluation may be appropriate in patients with: 

• Recurrent mitral regurgitation after prior repair 

• Severe mitral regurgitation with elevated pulmonary pressures 

• Anatomy that raises concern for obstruction 

• High surgical risk 

Early consultation does not commit a patient to intervention. It clarifies candidacy, strategy, and timing.