Author + information
- Received November 3, 2016
- Accepted November 17, 2016
- Published online February 6, 2017.
- Einar A. Hart, MD,
- Arco J. Teske, MD, PhD,
- Michiel Voskuil, MD, PhD,
- Pieter R. Stella, MD, PhD,
- Steven A.J. Chamuleau, MD, PhD and
- Adriaan O. Kraaijeveld, MD, PhD∗ ()
- ↵∗Address for correspondence:
Dr. Adriaan O. Kraaijeveld, Heidelberglaan 100, Utrecht 3584CX, the Netherlands.
We report a case of a 77-year-old male patient with a history of atrial fibrillation, ischemic dilating cardiomyopathy (left ventricular ejection fraction <20%), severe mitral regurgitation (MR), and a cured esophageal adenocarcinoma. He had symptomatic heart failure New York Heart Association functional class III/IV. The heart team deemed the patient unfit for conventional surgery and MitraClip (Abbott Vascular, Menlo Park, California) placement was recommended. Transcatheter MitraClip placement is traditionally performed using transesophageal echocardiography. However, the history of esophagectomy left the patient unfit for transesophageal echocardiography-guided MitraClip placement due to a significant stenosis at the esophagogastric junction and a blind pouch (Figure 1A).
To the best of our knowledge, we demonstrate the first ever successful treatment of severe MR through transthoracic echocardiography-guided MitraClip placement without general anesthesia.
Pre-procedurally, transthoracic echocardiography revealed severe grade 4/4 MR (Figure 1B) due to left ventricular dilation with retraction and displacement of the posterior (P1-P3) valve leaflet and retraction of the anterior (A1-A3) leaflet, resulting in malcoaptation. The effective regurgitant orifice was 0.80 cm2, with a regurgitant volume of 80 ml per beat and pulmonary vein systolic reversal. Adequate image acquisition in supine position including 3-dimensinal images (Online Video 1) was assessed pre-procedurally. During the procedure, transthoracic echocardiography was performed in supine position with the patient under conscious sedation. Transseptal puncture was guided by the 4- and 5-chamber apical view (Figure 1C), with careful assessment of needle position in relation to the aorta using the parasternal short axis view. Positioning of the MitraClip guide wire/catheter (Figure 1D) and subsequent introduction of the clip within the left ventricle was performed in the 2-, 3-, and 4-chamber apical view (Figures 1E and 1F). Two clips were successfully placed (Online Videos 2 and 3), 1 clip joining scallops at A3-P3 and one at A2-P2 (Figures 1G and 1H). The MR was reduced to grade 2 (Figure 1I) with an effective regurgitant orifice of 0.20 cm2 with a regurgitant volume of 24 ml per beat and partial restore of pulmonary vein systolic flow. Mean pressure gradient was 4.6 mm Hg at 96 beats per min. The post-operative course was uneventful.
For supplemental videos and their legends, please see the online version of this article.
Dr. Stella is a proctor for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 3, 2016.
- Accepted November 17, 2016.
- American College of Cardiology Foundation