Author + information
- Received August 29, 2013
- Accepted September 12, 2013
- Published online June 1, 2014.
- Robert Schueler, MD∗ (, )
- Nikos Werner, MD,
- Georg Nickenig, MD and
- Christoph Hammerstingl, MD
- Department of Internal Medicine II, Cardiology, Pulmonology, and Angiology, University of Bonn, Bonn, Germany
- ↵∗Reprint requests and correspondence:
Dr. Robert Schueler, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Str.25, 53105 Bonn, Germany.
A 71-year-old man was transferred to our clinic with acute decompensated chronic heart failure New York Heart Association functional class IV. He had a history of ischemic cardiomyopathy with severely reduced left ventricular function after coronary bypass surgery, aortic valve replacement, and restrictive mitral valve (MV) annuloplasty using a Carpentier-Edwards Perimount 23-mm ring (Edwards Lifesciences, Irvine, California) in 2012.
Three-dimensional (3D) transesophageal echocardiography (TEE) revealed partial detachment of the Carpentier ring, resulting in a large defect at the anterior MV leaflet in segment A3 with severe MV regurgitation (proximal isovelocity surface area: 1.4 cm, effective regurgitant orifice: 42 mm2, regurgitant volume: 59 ml/beat) (Figs. 1A and 1B).
The heart team's decision was to avoid repeated open-heart surgery because of relevant comorbidities (EuroSCORE [European System for Cardiac Operative Risk Evaluation] II: 12.42%). Because mitral regurgitation was caused by an anatomical defect of the MV leaflet without relapse of significant transvalvular regurgitation, we decided to perform an interventional defect closure with real-time 3D TEE guidance.
After placing a wire (Terumo Medical Corporation, Somerset, New Jersey) using a 5-F Terumo Glide catheter (Terumo Medical Corporation, Somerset, New Jersey) retrograde across the defect, transseptal puncture was performed establishing an arteriovenous loop by snaring the wire in the left atrium using a 20-mm Multi-Snare (B Braun, Melsungen, Germany) (Fig. 1C). Thereafter, a 10-F sheath (Amplatzer, St. Jude Medical, Plymouth, Minnesota) was inserted anterograde across the defect (Figs. 1D and 1E). After successful deployment of an Amplatzer ventricular septum defect occluder (Amplatzer VSD occluder, 14/5 mm), 3D TEE confirmed a relevant reduction of the MV regurgitation (Fig. 1E). Finally, the patient was discharged on day 5 after the procedure with improved functional New York Heart Association class II.
This is a rare case of partial detachment of an MV annuloplasty ring in which the anatomy of the mitral annulus was suitable for interventional defect closure. In this case, 3D TEE was an indispensable tool to identify the underlying pathology and for peri-interventional navigation during the complex procedure.
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The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 29, 2013.
- Accepted September 12, 2013.
- American College of Cardiology Foundation