Author + information
- Received June 24, 2009
- Revision received August 28, 2009
- Accepted September 4, 2009
- Published online February 1, 2010.
- Ben J.L. Van den Branden, MD⁎ (, )
- Martin J. Swaans, MD,
- Martijn C. Post, MD, PhD,
- Benno J.W.M. Rensing, MD, PhD,
- Frank D. Eefting, MD,
- Wybren Jaarsma, MD, PhD and
- Jan A.S. Van der Heyden, MD
- ↵⁎Reprint requests and correspondence:
Dr. Ben J. L. Van den Branden, Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, the Netherlands
A 45-year-old male patient, with a history of ischemic cardiomyopathy, peripheral arterial disease, and renal dysfunction, was admitted for percutaneous mitral valve repair. Cardiac magnetic resonance imaging showed an ejection fraction of 18% without viability. Severe mitral regurgitation (MR) occurred due to left ventricular annular dilation and restriction of the posterior leaflet (Fig. 1). Consequently, an important reduction in functional capacity (New York Heart Association class 3) was present. He was declined for surgery because of a predicted operative mortality rate of 36% (logistic EuroSCORE) and accepted for the percutaneous approach.
The procedure was performed under general anesthesia and guided with fluoroscopy and transesophageal echocardiography (3D-TEE, Philips probe, transducer X7-2t, Philips Healthcare, Best, the Netherlands). Access was gained using the right femoral vein, and after transseptal puncture the clip delivery system was advanced into the left atrium. The clip was successfully delivered into the left ventricle just below the mitral valve annulus and retrieved in the center of the maximal jet of the MR, which was located medial to the center of the annulus. After grasping the mitral valve leaflet edges, the clip was closed and released, creating a double mitral valve orifice. Unfortunately, 24 h later, transthoracic echocardiography showed clip detachment from the anterior mitral leaflet (Fig. 2A) without reduction in MR (Fig. 2B). A second clip was placed more centrally to maintain a better coaptation of the 2 leaflets (Fig. 3). The procedure was uneventful, and echocardiography confirmed adequate positioning of the second clip with substantial reduction in MR (Fig. 4). Reviewing the echocardiographic studies, the first clip was positioned too far to the medial (P1-A1) coaptation line. The selection of this position was guided upon what we assumed to be the maximum jet of regurgitation. Obviously, the real maximum jet was originating more lateral. Most probably, favoring the medial site, insufficient leaflet insertion was obtained. The patient was discharged 5 days later without clinical events related to the clip detachment. At 1 month, echocardiography showed mild MR (grade 2), unfortunately without clinical improvement. Because of persistent heart failure, he received a biventricular implantable cardioverter-defibrillator 3 months later.
Theoretically, partial clip detachment holds an increased risk of endocarditis, thrombus formation, and clip dislodgment with embolization. Therefore, we treated the patient with warfarin and clopidogrel. Furthermore, lifelong endocarditis prophylaxis was advised. At 6 months follow-up no such complications did occur, which is in line with recent findings of the EVEREST (Endovascular Valve Edge-to-Edge Repair Study) trial investigators (1).
- Received June 24, 2009.
- Revision received August 28, 2009.
- Accepted September 4, 2009.
- American College of Cardiology Foundation