Page 33 - Journal of Structural Heart Disease Volume 5, Issue 3

Case Report
72
with a complete ring and an annulus of 2.7 cm, severe residual MV regurgitation that is anteriorly directed and mean gradient of 3 mmHg, tricuspid annuloplas- ty with severe residual regurgitation and mean gra- dient 1 mmHg, and severe pulmonary hypertension, systolic pulmonary artery pressure 65 mmHg. Further evaluation by transesophageal echocardiography (TEE) to assess severity and direction of MV regurgita- tion (Figure 1-A), to measure the anterior and posteri- or mitral leaflet lengths which were 2.4 cm and 0.8 cm respectively and to assess pressure gradient across the MV (Figure 1-B). A coronary angiogram ruled out any significant coronary artery disease. She was placed on intensive medical therapy that included Bisoprolol 10mg daily, furosemide 40 mg twice daily, spironolactone 25 mg daily, metolazone 2.5 mg twice a week, valsartan 80 mg daily, atorvastatin 40 mg daily, apixaban 5 mg twice daily. In spite of medical therapy, she continued to suffer from dyspnea class III requiring admission and intravenous diuresis. Her options were discussed at the multidisciplinary team meeting. She was deemed too high risk for a redo sur- gery. An off-label use of the MitraClip System was also discussed and offered to the patient.
Procedure
The procedure was performed under general an- esthesia administered by a cardiac anesthetist and using fluoroscopic and transesophageal echocardio- graphic guidance. Both arterial and venous access- es were obtained in the common femoral vein and artery. Through the venous sheath, the trans-septal puncture was achieved superiorly (3.6 cm distance from the puncture site to the mitral valve annulus) and posteriorly with TEE assistance. Heparin was administered and a therapeutic ACT ( > 300) was maintained throughout the procedure. The delivery sheath was advanced into the left atrium over a 0.035 inch stiff Amplatz wire. With delicate maneuvering the MitraClip was positioned and perpendicularity was confirmed guided by 3-dimensional transesoph- ageal echocardiography (Figure 1-C). The clip was ini- tially advanced more posteriorly with marked medial deflection (the knob was angled to 90 degrees medi- ally). After diving into the left ventricle in closed posi- tion to a level just below the ring, the clip was opened.
Perpendicularity and alignment were confirmed just below the level of the leaflets using both fluoroscopic visualization of the ring and TEE imaging. More medi- al and anterior dialing was necessary for appropriate positioning of the clip. Upon pulling back up, both leaflets were grasped. Grasping was particularly easy given the limited excursion of the leaflets at this point, TEE evaluation revealed adequate grasp of both ante- rior and posterior MV leaflets, trace residual MV regur- gitation (Figure A-D), and a mean gradient of 5 mmHg (Figure 2-A) and no pericardial effusion. Fluoroscopic assessment of the Mitral Clip alignment and perpen- dicularity below the annuloplasty ring was checked in Right Anterior Oblique 10 degree view before and after release of the device (Figure 2-B, C). Of note, she developed atrial fibrillation during the procedure which was successfully cardioverted using 200 J.
Her immediate post-procedure course was un- eventful and her anticoagulation was resumed. Over the next four weeks, she showed significant clini- cal improvement and a follow up echocardiogram showed sustained results with remarkable reduction in her tricuspid regurgitation and negligible residual mitral regurgitation. She remained in sinus rhythm. The mean gradient across the mitral valve remained 5 mmHg. Accordingly, her medications were re-adjust- ed and decreased to include Bisoprolol 2.5mg daily, valsartan 80 mg daily, spironolactone 25 mg daily, atorvastatin 40 mg daily, and apixaban 5 mg twice daily. Both her furosemide and metolazone were dis- continued.
Discussion
Surgical repair of the mitral valve remains the first line option for severe symptomatic mitral re- gurgitation. Percutaneous therapies have become a reasonable option for patients who are deemed too high risk for surgery. However, these percutaneous devices have not been approved for use in patients with previous surgical repair or annuloplasty rings. Although data suggests that up to 13% of individu- als develop severe regurgitation after surgical repair, such post-operative patients have no options if their co-morbidities preclude a redo surgery. Often inten- sifying medical therapy is not sufficient to reduce hospitalizations for recurrent pulmonary edema or to
Journal of Structural Heart Disease, June 2019
Volume 5, Issue 3:70-74