Author + information
- Received August 13, 2018
- Accepted August 21, 2018
- Published online November 5, 2018.
- Noriaki Tabata, MD,
- Marcel Weber, MD,
- Jan-Malte Sinning, MD,
- Fritz Mellert, MD,
- Georg Nickenig, MD and
- Nikos Werner, MD∗ ()
- International Center for Cardiovascular Interventions, Herzzentrum Bonn, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany
- ↵∗Address for correspondence:
Dr. Nikos Werner, International Center for Cardiovascular Interventions, Herzzentrum Bonn, Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany.
An 83-year-old woman presented with progressive dyspnea in New York Heart Association functional class III. Echocardiography showed preserved left ventricular ejection fraction, severe mitral regurgitation (MR), and posterior mitral leaflet prolapse (segments P1 and P2) (Figure 1A, Online Video 1). By transapical off-pump reconstruction using the NeoChord DS1000 system (NeoChord, Saint Louis Park, Minnesota), 3 tendons were successfully implanted, with a significant reduction in MR (grade I to II) (Figure 1B, Online Video 2) and alleviation of symptoms (New York Heart Association functional class I to II).
Six months later, the patient presented again with rapidly progressive dyspnea (New York Heart Association functional class IV). Echocardiography revealed rupture of the implanted NeoChord at the apex, with resulting high-grade MR (Figures 1C to 1E, Online Videos 3A, 3B, and 3C). The heart team decided on an interventional approach using the new MitraClip XTR system (Abbott Vascular, Santa Clara, California), and despite the massive leaflet flail, effective grasping in segment A2-P2 was achieved (residual MR grade I, mean pressure gradient 2 mm Hg) (Figure 1F, Online Video 4).
There are some reports of on-pump-implanted neochordal ruptures after months to 10 years, and the possible etiologies in the present case might be intraoperative trauma to the suture material and/or mechanical rupture due to intracardiac tension. This is the first case report of transapically implanted NeoChord rupture and successful bailout using the newly emerged MitraClip XTR. This new system has longer clip arms and grippers, leading to more effective grasping of leaflets also in cases with larger coaptation defects, designated for first-line therapy or for successful bailout, as in this case.
Dr. Tabata was supported financially in part by the Fellowship of Astellas Foundation for Research on Metabolic Disorders. Dr. Sinning has received speaker honoraria and research grants from Medtronic, Edwards Lifesciences, and Boston Scientific. Dr. Werner has received speaker honoraria from Abbott Vascular. Drs. Mellert and Nickenig have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 13, 2018.
- Accepted August 21, 2018.
- 2018 American College of Cardiology Foundation