Author + information
- Received April 21, 2015
- Accepted April 24, 2015
- Published online September 1, 2015.
- Rakesh M. Suri, MD, DPhil∗,†∗ (, )
- Joseph F. Malouf, MD†,‡,
- Vuyisile T. Nkomo, MD, MPH‡,
- Erica D. Wittwer, MD, PhD§,
- Richard C. Daly, MD† and
- Charanjit S. Rihal, MD, MBA‡
- ∗Department of Thoracic and Cardiovascular Surgery, Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
- †Divison of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota
- ‡Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
- §Division of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota
- ↵∗Reprint requests and correspondence:
Dr. Rakesh M. Suri, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Abu Dhabi, P.O. Box 112412, Abu Dhabi, United Arab Emirates.
We describe a novel method of MitraClip (Abbott Vascular, Santa Clara, California) delivery via the right superior pulmonary vein in a patient with an impassable interatrial septum. The patient had a history of 2 median sternotomies for coronary artery revascularization and aortic valve replacement. He presented with New York Heart Association functional class IV symptoms and congestive heart failure associated with severe mitral regurgitation due to posterior mitral leaflet prolapse. The patient had multiple comorbidities including paroxysmal atrial fibrillation, chronic pleural effusions, and dialysis-dependent renal failure and was thus deemed to be an unsuitable candidate for third time repeat sternotomy and mitral valve repair. Owing to the existence of a thickened septum caused by marked lipomatous hypertrophy (Figure 1) and unsuccessful crossing attempts associated with inadvertent puncture of the pulmonary artery, direct left atrial access for MitraClip delivery was considered. We describe the technical features of the procedure during which a right chest, fourth intercostal space miniport was fashioned (Figure 2), and emergency wire access for cardiopulmonary bypass support was prophylactically secured via the right common femoral vessels. Two-dimensional transesophageal echocardiography (TEE) suggested a flail medial scallop of the posterior mitral leaflet (Figure 3), which was confirmed using 3-dimensional TEE (Figure 4). Using a Seldinger technique via a thoracoscopically placed purse-string suture at the junction of the right superior pulmonary vein and left atrium, the MitraClip delivery sheath was directly inserted just through the mitral valve orifice (Figure 5). The first of 2 MitraClip devices were delivered (Figure 6) to correct posteromedial scallop prolapse. Residual MR necessitated the delivery of a second device through the same MitraClip sheath held stable in position during loading of the second device (Figure 7). TEE demonstrated the diminution of severe mitral regurgitation to mild after delivery of both MitraClip devices (Figure 8), after which the sheath was removed and the pulmonary vein purse string tied to secure hemostasis.
Dr. Suri is a member of the Clinical Screening Committee for the Abbott COAPT Trial. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 21, 2015.
- Accepted April 24, 2015.
- American College of Cardiology Foundation