Author + information
- Received September 5, 2018
- Revision received November 19, 2018
- Accepted November 26, 2018
- Published online January 21, 2019.
- Tiberio M. Frisoli, MDa,∗ (, )
- Adam Greenbaum, MDb,
- William W. O’Neill, MDa,
- Dee Dee Wang, MDa and
- Marvin Eng, MDa
- aCenter for Structural Heart Disease, Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
- bStructural Heart and Valve Center, Emory University Hospitals, Atlanta, Georgia
- ↵∗Address for correspondence:
Dr. Tiberio M. Frisoli, Center for Structural Heart Disease, Heart and Vascular Institute, Henry Ford Hospital, Clara Ford Pavilion, 4th Floor, 2799 West Grand Boulevard, Detroit, Michigan 48202.
An obese 61-year-old woman on hemodialysis with severe symptomatic mitral regurgitation (MR) due to A2 scallop perforation (Figure 1), at high risk for surgical valve replacement (Society of Thoracic Surgeons risk for mortality 13%), underwent transcatheter mitral repair. After 1 MitraClip (Abbott Vascular, Santa Clara, California) was deployed at A2/P2 to stabilize leaflets, a JL 4.5 guiding catheter positioned retrograde in the left ventricular outflow tract allowed delivery of an angled Glidewire (Terumo, Tokyo, Japan) across the perforation. The wire was externalized out the right common femoral vein. A 6/4 Amplatzer Duct Occluder II (St. Jude Medical, St. Paul, Minnesota) deployed in the perforation was too small and was retrieved. A 15-mm Gore Cardioform device (W.L. Gore, Newark, Delaware) was deployed, but upon release of the occluder lock, the delivery system sprung superiorly and deformed the proximal (in this case left atrial) disc of the occluder (Figure 2, Online Video 1), which necessitated recapturing. An 18-mm Amplatzer PFO Occluder device (St. Jude Medical) was deployed, with reduction in MR to mild to moderate. The patient had hemolytic anemia requiring transfusions, which fortunately subsided after 6 months. She is alive, in New York Heart Association functional class II, with mild MR on recent echocardiography and with no heart failure admissions, now 23 months post-procedure.
A 66-year-old man with severe symptomatic MR due to A1 scallop perforation, at high risk for surgery (despite Society of Thoracic Surgeons risk for mortality of 1%) because of hepatitis C liver cirrhosis, underwent transcatheter mitral repair. After MitraClip deployment at the medial margin of A1/P1, a Cardioform delivery catheter, with its blunt tip, did not cross the perforation over a stiff-angled Glidewire, but an 8-F TorqVue (St. Jude Medical) with dilator did, allowing delivery of the Cardioform device. The Cardioform was deployed not in the normal fashion (Figure 3) but rather “backward” by performing step B before step A (Figure 3), so that release of the delivery system did not deform the device (Online Video 2). He is alive, in New York Heart Association functional class I, with trivial MR on recent echocardiography, with no evidence of hemolysis and no heart failure admissions, now 15 months post-procedure.
A 57-year-old man with history of obesity, chronic obstructive pulmonary disease, chronic kidney disease stage III, colon cancer, stroke, and severe symptomatic MR had a perforated A1 scallop extending from the base of the scallop to the leaflet tip (Figure 4). He was deemed at elevated risk for surgery (though Society of Thoracic Surgeons risk for mortality was only 4%) and thus underwent transcatheter mitral repair as in our second case, reducing MR to mild (Online Video 3). His post-procedure and 1-month echocardiograms showed mild MR, but he unfortunately died 4 months post-procedure in the context of a recent emergency department visit for soft tissue infection of the leg and acute and chronic kidney injury.
None of these 3 patients demonstrated any clinical features of active endocarditis, and all had negative pre-procedural blood cultures. A stepwise summary of the transcatheter repair as performed by our group is illustrated in Figure 5 and differs from prior reported transcatheter repairs (1,2). We used the MitraClip to stabilize the mitral valve leaflets to reduce the risk for occluder-related leaflet malcoaptation and de novo MR and for occluder embolization.
Whether the Cardioform is associated with less hemolysis than the Amplatzer device for this application cannot be concluded from these cases.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 5, 2018.
- Revision received November 19, 2018.
- Accepted November 26, 2018.
- 2019 American College of Cardiology Foundation