Author + information
- Received May 25, 2016
- Accepted June 3, 2016
- Published online September 12, 2016.
- Mohamad Alkhouli, MD,
- Abdallah El Sabbagh, MD,
- Hector R. Villarraga, MD,
- Donald J. Hagler, MD,
- Charanjit S. Rihal, MD, MBA and
- Mackram F. Eleid, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Mackram F. Eleid, Mayo Clinic, Department of Cardiovascular Diseases, 200 First Street SW, Rochester, Minnesota 55905.
Significant residual mitral regurgitation (MR) may persist after MitraClip (Abbott Vascular, Santa Clara, California) implantation in up to 7% of patients with degenerative MR (1). Treatment of the residual MR with an adjacent MitraClip may not be feasible, because of commissural location, cleft, or perforation. The feasibility of Amplatzer Vascular Plug II (AVP-II, St. Jude Medical, St. Paul, Minnesota) implantation between 2 MitraClips to treat residual “intraclip” MR has been recently demonstrated (2,3). However, the use of the AVP-II device to treat commissural “periclip” MR when only 1 MitraClip is placed has not been reported.
A 69-year-old woman with a history of severe chronic obstructive lung disease (forced expiratory volume in 1 second 29% of predicted) and remote native mitral valve endocarditis, treated with appropriate antibiotic therapy 3 years previously, presented for evaluation of severe primary MR. She was initially minimally symptomatic but recently developed progressive dyspnea of 6 months’ duration. After a multidisciplinary evaluation, transcatheter mitral valve repair was the favored approach, as her surgical risk was deemed prohibitive because of her severe pulmonary disease.
Transesophageal echocardiography revealed severe MR with a regurgitant volume of 100 ml and systolic Doppler flow reversals in the pulmonary veins (Online Video 1). There was a small unsupported P1 segment with a cleft-like indentation likely related to previous endocarditis. A MitraClip device was implanted at the lateral aspect of the A2-P2 commissure (Figure 1A, Online Video 2). Post-procedure, there was a slight reduction in MR severity to moderate to severe and no pulmonary venous systolic flow reversals. The residual regurgitant jet originated lateral to the MitraClip at the unsupported P1 segment.
At 1-month follow-up, the patient had no significant change in her dyspnea or 6-min walk distance compared with her pre-procedure baseline. Therefore, the decision was made to attempt AVP-II implantation lateral to the MitraClip to reduce the degree of residual regurgitation.
A 14-F introducer (Cook Medical, Bloomington, Indiana) was placed in the right femoral vein. Left atrial access was obtained with a Mullins transseptal introducer sheath and a Brockenbrough needle (Medtronic, Minneapolis, Minnesota) through the midposterior fossa ovalis. An Inoue wire was advanced into the left atrium and the septum was dilated with a 14-F Inoue dilator (Toray Medical, Tokyo, Japan). A large-curl Agilis steerable introducer (St. Jude Medical) was advanced into the left atrium and steered toward the regurgitant jet. A telescoping system (100-cm 7-F multipurpose guide and 120-cm 5-F multipurpose catheter) with a 260-cm stiff angled Glidewire (Terumo, Tokyo, Japan) was used to cross the mitral valve lateral to the MitraClip at the A1/P1 segment. A pre-curved Amplatz extra stiff wire (Boston Scientific, Marlborough, Massachusetts) was placed in the left ventricle to deliver the AVP-II device. Initially, a 14-mm plug was deployed via the 7-F multipurpose guide, resulting in a reduction in MR grade to mild (Online Video 3). However, over the next 20 min, there was atrial displacement of the plug with worsening MR noted on transesophageal echocardiographic imaging (Figures 1 and 2, Online Video 4). Therefore, the device was retrieved with a 6-F 30-mm EnSnare (Merit, South Jordan, Utah). The defect was crossed again in the same fashion, and an 18-mm AVP-II was deployed through a 9-F 75-cm Mullins sheath, with reduction of MR severity to mild and excellent device stability (Figure 3). Following placement of the AVP-II device, the left atrial v wave decreased from 30 to 20 mm Hg (Figure 4). The mean diastolic transmitral gradient was 3 mm Hg. Follow-up transthoracic echocardiography at 24 h showed trivial MR (Online Video 5). The patient was discharged home in a stable condition the following day. This first-in-human report demonstrates the feasibility of treating residual commissural “peri-MitraClip” MR with an AVP-II device.
For supplemental videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Alkhouli and El Sabbagh contributed equally to this work.
- Received May 25, 2016.
- Accepted June 3, 2016.
- 2016 American College of Cardiology Foundation
- Sorajja P.,
- Mack M.,
- Vemulapalli S.,
- et al.
- ↵Taramasso M, Zuber M, Gaemperli O, et al. Amplatzer devices to treat residual mitral regurgitation after MitraClip: a preliminary feasibility study. Abstract EuroPCR 2015. Available at: http://www.pcronline.com/eurointervention/AbstractsEuroPCR2015/abstracts-europcr-2015/POS267/amplatzer-devices-to-treat-residual-mitral-regurgitation-after-mitraclip-a-preliminary-feasibility-study.html. Accessed June 28, 2016.