Author + information
- Received May 31, 2016
- Revision received June 13, 2016
- Accepted June 20, 2016
- Published online September 26, 2016.
- Azeem Latib, MBBCha,b,∗ (, )
- Marco B. Ancona, MDb,
- Luca Ferri, MDb,
- Matteo Montorfano, MDb,
- Antonio Mangieri, MDb,
- Damiano Regazzoli, MDb,
- Francesco Giannini, MDb,
- Fabrizio Monaco, MDc,
- Manuela Giglio, MDd,
- Stefano De Servi, MDe,
- Ottavio Alfieri, MDf,
- Antonio Colombo, MDa,b and
- Eustachio Agricola, MDb
- aInterventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
- bInterventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
- cDepartment of Cardiac Anesthesia, San Raffaele Scientific Institute, Milan, Italy
- dCentre for Cardiovascular Prevention, San Raffaele Scientific Institute, Milan, Italy
- eCoronary Care Unit, IRCCS Policlinico San Matteo, Pavia, Italy
- fDepartment of Cardiothoracic Surgery, EMO-GVM Centro Cuore Columbus, San Raffaele Scientific Institute, Milan, Italy
- ↵∗Reprint requests and correspondence:
Dr. Azeem Latib, EMO-GVM Centro Cuore Columbus, Via Buonarroti 48, Milan 20145, Italy.
- direct annuloplasty
- functional mitral regurgitation
- transcatheter mitral valve intervention
A 74-year-old man was referred for worsening symptoms of left-sided heart failure (New York Heart Association functional class III) 1 year after undergoing an edge-to-edge repair with 2 MitraClips (Abbott Vascular, Santa Clara, California) for functional mitral regurgitation (FMR) at another institution (Figure 1A). His history included ischemic cardiomyopathy, previous coronary bypass surgery, and implantable cardioverter-defibrillator placement. Transesophageal echocardiography confirmed severe left ventricular dysfunction (ejection fraction 35%), severe pulmonary hypertension, marked mitral annular dilation (Figure 1B), and severe FMR with multiple jets originating from between the clips and both anterolateral and posteromedial orifices (Figure 1C). In an attempt to reduce the FMR, reducing annular dilation and increasing leaflet coaptation and thus to alleviate the patient’s symptoms, we performed direct annuloplasty with the Cardioband system (Valtech Cardio, Or Yehuda, Israel) (1). The Cardioband was implanted using a transfemoral-transseptal approach on the posterior annulus from the anterolateral to posteromedial commissure using 16 anchors (Figures 1D and 1E). The implant was cinched, resulting in significant reduction in annular diameters (Figures 1G and 1H) and marked reduction in FMR (Figure 1I).
The current report demonstrates the feasibility of percutaneous direct annuloplasty as a treatment option in patients with FMR treated with the MitraClip presenting with persistent annular dilation and recurrent mitral regurgitation. Direct annuloplasty after MitraClip placement presents challenges with regard to imaging caused by artifacts and the immobility of the posterior leaflet, which makes it difficult to distinguish the hinge point of the leaflet and thus the annulus from the leaflet. This case also highlights the possibility of performing a fully percutaneous mitral valve repair (edge-to-edge plus annuloplasty) and thus surgical-type correction of FMR. However, from a practical and theoretical perspective, direct annuloplasty should be performed before MitraClip placement, as it may facilitate leaflet grasping and reduce the risk for recurrent mitral regurgitation.
Dr. Latib is a consultant for Medtronic and Direct Flow Medical. Dr. Montorfano is a proctor for St. Jude Medical and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 31, 2016.
- Revision received June 13, 2016.
- Accepted June 20, 2016.
- American College of Cardiology Foundation