Author + information
- Received January 22, 2018
- Accepted February 6, 2018
- Published online July 16, 2018.
- Fábio S. de Brito Jr., MD, PhD∗ (, )
- Felipe Nasser, MD, PhD,
- Rodrigo Gobbo, MD, PhD,
- Pedro Lemos, MD, PhD,
- Marcelo Vieira, MD, PhD,
- Claudio Fischer, MD, PhD,
- José Mariani Jr., MD,
- Francisco L. Galastri, MD,
- Marcelo Franken, MD, PhD and
- José Renato M. Martins, MD
- ↵∗Address for correspondence:
Dr. Fábio Sandoli de Brito Jr., Rua Armando Petrella 431, 19/2, 05679-010 São Paulo, Brazil.
The femoral venous approach for percutaneous edge-to-edge repair of the mitral valve with the MitraClip system (Abbott Vascular, Santa Clara, California) may not be possible in patients with occlusion or congenital anomalies of the inferior vena cava (IVC) or limited by the presence of an IVC filter. In these situations, the use of the percutaneous transhepatic venous access may be an alternative. We report the first to our knowledge MitraClip procedure using this approach.
A 52-year-old woman presenting with New York Heart Association (NYHA) class IV symptoms due to idiopathic dilated cardiomyopathy with an ejection fraction of 25%, and severe functional mitral regurgitation was referred for percutaneous mitral valve repair with the MitraClip system. The transfemoral venous access was initially attempted but found not to be feasible due to the presence of left-sided IVC continuing as the hemiazygos and azygos veins, and draining into the superior vena cava and right atrium (Online Video 1). At this point, the procedure was aborted and a multislice computed tomography scan was performed, confirming the IVC anomaly and depicting the drainage of the normal-sized hepatic veins directly into the right atrium (Figure 1). Three days later, the MitraClip procedure was accomplished using a percutaneous transhepatic approach. In brief, a 22-ga needle was inserted below the ribs in the right anterior axillary line to cannulate the middle hepatic vein with guidance of electromagnetic tracking-based fusion imaging of computed tomography and real-time ultrasound (Figure 2). The middle hepatic vein was chosen due to its more vertical orientation in relation to the heart. A wire was advanced into the right atrium, and the transseptal puncture was performed without difficulty under transesophageal echocardiogram guidance. At this point, intravenous heparin was administered. A Safari wire (Boston Scientific, Natick, Massachusetts) was positioned in the left atrium and, after dilating the intrahepatic segment with a 14-F sheath, the 24-F MitraClip steerable guiding catheter was advanced into the left atrium (Figure 2). One MitraClip was deployed with reduction of the regurgitation from 3+/4+ to 1+ (Figures 2 and 3). At the end of the procedure, heparin was reversed, and the guiding catheter was withdrawn from the hepatic vein and positioned within the liver parenchyma just outside the vein lumen. A 10-mm Amplatzer Vascular Plug II (St. Jude Medical, Saint Paul, Minnesota), 2 coils (0.038-inch × 5 cm × 5 mm), and Gelfoam sponge were placed within the lumen of the hepatic tract to secure hemostasis (Figure 2). Four-month follow-up revealed NYHA functional class II symptoms and 1+ mitral regurgitation.
The percutaneous transhepatic venous access has been reported to be feasible and used in electrophysiology and diagnostic and interventional cardiovascular procedures in children and adults (1–3). This alternative approach might be useful for structural heart disease interventions requiring atrial septal crossing with large-sized catheters when access to the heart from the femoral approach is not possible.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 22, 2018.
- Accepted February 6, 2018.
- 2018 American College of Cardiology Foundation