Author + information
- Received September 24, 2013
- Accepted September 28, 2013
- Published online June 1, 2014.
- Gian Paolo Ussia, MD∗ (, )
- Valeria Cammalleri, MD,
- Domenico Sergi, MD,
- Pasquale De Vico, MD and
- Francesco Romeo, MD
- ↵∗Reprint requests and correspondence:
Dr. Gian Paolo Ussia, Department of Cardiovascular Disease, Tor Vergata University of Rome, Viale Oxford, 81, 00133 Rome, Italy.
Transcatheter repair of mitral regurgitation (MR) with the MitraClip System (Abbott Vascular, Abbott Park, Illinois) requires specific echocardiographic criteria (1,2). Suboptimal results after standard MitraClip repair have been associated with a coaptation length <2 mm, coaptation depth ≥11 mm, coaptation gap >0.7 cm between the anterior and posterior leaflets, and a jet width >15 mm (1–3).
We report a case of a 77-year-old man with ischemic severe functional MR, atrial fibrillation, and chronic renal failure. He was in New York Heart Association (NYHA) functional class IV, despite optimal medical therapy. Because of his high surgical risk (STS score 20,26% and logistic EuroSCORE 50,65%), he was referred to us for transcatheter mitral valve repair. Echocardiography confirmed severe MR (Fig. 1A), as a result of extreme bileaflet tethering, measuring a jet width of 18 mm along the coaptation rim (Fig. 1B) and a coaptation gap of 0.8 cm (Fig. 1C); the left ventricular ejection fraction was estimated to be 25%.
The unfavorable echocardiographic anatomy anticipated a failure with the standard approach. Therefore, the strategy adopted consisted of implanting 2 clips starting from the anterolateral commissure following a lateral to medial direction (Figs. 1D and 1E), in order to reduce the annular perimeter and improve the coaptation between A2 and P2. A double-orifice mitral valve was then created placing a third clip in the middle scallops (Figs. 1F to 1J, Online Video 1) and obtaining a significant MR reduction (Figs. 1K and 1L). The patient was discharged 5 days later in NYHA functional class II.
This technique, consisting of annulus remodeling in order to improve the coaptation in case of a large gap in the leaflets and a wide jet extension, is a feasible approach for treating complex mitral valve anatomies.
For accompanying videos, please see the online version of this paper.
Dr. Ussia has been a medical proctor for Medtronic; and has received honoraria (speaker's fees) from Abbott Vascular (speaker honoraria). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 24, 2013.
- Accepted September 28, 2013.
- American College of Cardiology Foundation
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