Author + information
- Received June 2, 2016
- Accepted June 20, 2016
- Published online September 26, 2016.
- Zouhair Rahhab, MDa,
- Ben Ren, MD, PhDa,
- Frans Oei, MD, PhDb,
- Peter P.T. de Jaegere, MD, PhDa and
- Nicolas M. Van Mieghem, MD, PhDa,∗ ()
- aDepartment of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
- bDepartment of Thoracic Surgery, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
- ↵∗Reprint requests and correspondence:
Dr. Nicolas M. Van Mieghem, Department of Interventional Cardiology, Thoraxcenter, Erasmus MC, Room Bd 171, ’s Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands.
A 68-year-old wheelchair-dependent female with diabetes and end-stage kidney failure presented with symptomatic severe functional mitral regurgitation (MR) (Figure 1A) and a left ventricular ejection fraction of 37%. The multidisciplinary heart team reached consensus for MitraClip (Abbott Vascular, Santa Clara, California, implantation because of high operative risk (Society of Thoracic Surgeons 8.5) and frailty.
The MitraClip procedure was performed under general anesthesia and 2-dimensional and 3-dimensional transesophageal echocardiography guidance. After multiple attempts of leaflet grasping and clipping along the mitral coaptation plane, 2 MitraClips were released at the level of A2-P2 and A1-P1. A third clip toward the posteromedial commissures was attempted because of persistent severe MR (Figure 1B to 1C) and markedly reduced the MR, albeit at the expense of an unacceptably high transmitral mean gradient up to 9 mm Hg. Intraprocedural transesophageal echocardiography revealed ruptured chordae and a perforation in the posterior leaflet (Figure 1D to 1F). The third clip was therefore not released and the patient was sent for high-risk mitral valve surgery. Perioperatively, the mitral valve seemed to be injured severely with partial clip dehiscence at the level of A2-P2, including a tear in the posterior mitral leaflet, several chordal ruptures, and leaflet damage at the level of P3 (Figure 1G to 1I). The mitral valve was replaced with a 29-mm St. Jude mechanoprothesis with excellent final results (no MR, no significant gradient).
This case report illustrates that leaflet grasping and clipping attempts during a MitraClip procedure may not be trivial and may significantly damage the mitral apparatus requiring surgical bailout. A multidisciplinary approach is essential in terms of MitraClip patient selection, procedure execution and problem solving.
The Erasmus Medical Center has received research grant support from Boston Scientific and Abbott Vascular.
- Received June 2, 2016.
- Accepted June 20, 2016.
- American College of Cardiology Foundation