Author + information
- Received April 17, 2017
- Revision received May 1, 2017
- Accepted May 9, 2017
- Published online August 2, 2017.
- Damiano Regazzoli, MDa,
- Alfonso Ielasi, MDb,
- Giuseppe Lanzillo, MDa,
- Marco Bruno Ancona, MDa,
- Eustachio Agricola, MDc,
- Francesco Giannini, MDa,
- Antonio Mangieri, MDa,
- Francesco Ancona, MDc,
- Jorg Hausleiter, MDd,
- Michael Nabauer, MDd,
- Antonio Colombo, MDa and
- Azeem Latib, MDa,∗ ()
- aInterventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- bCardiology Unit, Bolognini Hospital, Seriate, Italy
- cNoninvasive Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy
- dMedizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität, Munich, Germany
- ↵∗Address for correspondence:
Dr. Azeem Latib, Interventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20145 Milan, Lombardy, Italy.
A 73-year-old woman presented with heart failure, systemic congestion, and fatigue despite optimal medical therapy. Her medical history included stage IV kidney disease and previous hepatitis B virus infection.
In 2014, she experienced a non–ST-segment elevation myocardial infarction: coronary angiography was performed and showed 2-vessel disease with stenosis of the left anterior descending artery that was treated with drug-eluting stent implantation; chronic total occlusion of right coronary artery was also found and left to medical therapy. She underwent dual-chamber permanent pacemaker (PM) implantation for third-degree atrioventricular block a year later. After this last procedure, progressive tricuspid regurgitation (TR) developed. This finding was confirmed at echocardiography performed at admission (Figure 1, Online Video 1): TR was secondary to annular dilation and PM lead interference with the septal leaflet. Both right and left ventricular function, as well as pulmonary pressure, were normal.
Pacing leads in the right ventricle (RV) are present in 40% to 50% of patients with severe TR, and an increased mortality rate has been observed in this population, compared with those with TR, but no PM (1). In the present case, the pacing lead may have actively contributed to the mechanism of TR by displacing the septal leaflet and by causing asynchrony in RV contraction (2). Furthermore, the presence of this foreign body across the valve may interfere with potential surgical or percutaneous treatment for TR (3).
After heart team discussion, the patient was deemed inoperable and was then evaluated for percutaneous transcatheter tricuspid repair with MitraClip system (Abbott Vascular, Santa Clara, California). The procedure was performed under general anesthesia with fluoroscopic and transesophageal echocardiographic guidance via percutaneous right transfemoral venous access. The guiding catheter was placed into the right atrium, and a clip was then advanced through the transcatheter valve and oriented in order to reach the anteroseptal commissure (Figures 2A and 2B). A second clip was advanced near the first one, toward the posteroseptal commissure (Figures 2C and 2D), thus effectively excluding the lead into the commissure and substantially reducing TR (Figure 2E and 2F, Online Video 2). The patient was discharged on post-operative day 2, with mild residual TR (Figure 3A, Online Video 3). At 6-month follow-up, she reported clinical improvement with reduction in lower limb edema and fatigue; echocardiography confirmed the consistent reduction of TR (Figure 3B).
In this specific setting, percutaneous transcatheter valve repair with the MitraClip system seems to be a promising option with minimal procedural risk as well as good and sustained clinical and echocardiographic results.
For supplemental videos and their legends, please see the online version of this paper.
Dr. Latib is a consultant for, has received speaking honoraria from, and has active research studies for Mitralign, Valtech Cardio, 4-Tech, Abbott Vascular, and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 17, 2017.
- Revision received May 1, 2017.
- Accepted May 9, 2017.
- 2017 American College of Cardiology Foundation
- Delling F.N.,
- Hassan Z.K.,
- Piatkowski G.,
- et al.
- Stryjewski P.J.,
- Osika A.,
- Kuczaj A.,
- et al.