Author + information
- Received September 24, 2014
- Accepted November 22, 2014
- Published online April 27, 2015.
- Rajiv Goswami, DO∗ (, )
- Barker Colin, MD,
- Matthew Jackson, MSc,
- Neal Kleiman, MD and
- Stephen Little, MD
- ↵∗Reprint requests and correspondence:
Dr. Rajiv Goswami, Houston Methodist Hospital, Heart & Vascular Center, 6565 Fannin Street, Houston, Texas 77030.
A 67-year-old woman with coronary artery disease, peripheral vascular disease, and end-stage renal disease on hemodialysis presented with refractory decompensated congestive heart failure. Echocardiography showed severe mitral regurgitation from 2 sources: poor leaflet coaptation due to tethering of the posterior leaflet and a perforation at the base of the posterior leaflet (Figure 2⇓). Cardiothoracic surgery declined to perform a surgical valve replacement due to high operative risk.
We tested various devices in an explanted canine mitral valve with a perforation created on the posterior mitral leaflet to simulate the pathology in our patient. The Amplatzer Duct Occluder II (St. Jude Medical, St. Paul, Minnesota) appeared to seal the defect with a stable position and minimal interference in leaflet and chordae function (Figure 1).
With the patient under general anesthesia and 3-dimensional transesophageal echocardiography guidance (Figures 3 and 4⇓⇓), a guidewire was directed across the perforation with the assistance of the Agilis steerable introducer (St. Jude Medical), placed in the left atrium through a transseptal puncture (Figure 4). A 6 × 4-mm Amplatzer Duct Occluder II device was deployed across the perforation (Figure 5). Left atrial pressure measurements showed an acute reduction in the V-wave from 60 to 40 mm Hg.
Repeat echocardiography showed a reduction in total mitral regurgitation with complete seal of the perforation by the device (Figure 6). Her left atrial volume decreased from 84 ml to 67 ml, and left ventricular function remained at 55%. She was weaned off inotropes, discharged home and continues to make clinical progress.
For supplemental videos and their legends, please see the online version of this article.
Dr. Little has received research support and speaking honoraria from St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 24, 2014.
- Accepted November 22, 2014.
- American College of Cardiology Foundation