Page 34 - Journal of Structural Heart Disease Volume 5, Issue 3

73 Case Report
Figure 2. Panel A. Fluoroscopic visualization of the closed Mitral Clip below the annuloplasty ring in Right Anterior Oblique 10 degree view. Panel B. Fluoroscopic assessment of the open Mitral Clip alignment & perpendicularity below the annuloplasty ring in Right Anterior Oblique 10 degree view. Panel C. Released Mitral Clip seen fluoroscopically in situ.
improve quality of life. Off label use of devices, such as in this case, maybe the only reasonable approach. This requires a transparent discussion with the pa- tient indicating the off label use, lack of long term data and entailed risks.
From a technical point of view, a high trans-septal puncture is necessary to allow comfortable manipu- lation of the device. Correlation with TEE is imperative as the device is positioned to clear the annuloplasty ring. Diving may need to be limited to the level just below the valve leaflets and annulus to avoid entan- glement at the chordae as the jet is very eccentric. Af- ter diving, further manipulation may be necessary to position the clip at the jet while maintaining perpen-
dicularity. Meticulous assessment by TEE ascertaining adequate grip is a crucial step.
Patients with a previously repaired valve often have a gradient across the mitral valve. Upon place- ment of the clip, the mean gradient will increase fur- ther. It is important to realize that these patients likely will not tolerate a second clip as the gradient will be too high (over 7 mmHg). Appropriate positioning of the clip, optimizing medical therapy and maintaining sinus rhythm are all equally important in reducing the gradient to what the patient can tolerate. In our pa- tient, her initial gradient was 3 mmHg. Post MitraClip placement, the gradient was maintained at 5 mmHg after we converted her to sinus rhythm.
Bokhari F. et al.
MitraClip Post Annuloplasty