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    Failed MitraClip procedure with pull out of the anterior leaflet

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        MitraClip is an attractive and less invasive alternative to mitral valve surgery in serve mitral regurgitation in patients with moderate or severe risk for operation. It has been described to be effective and safe in functional as well as in degenerative mitral regurgitation. We report a case of MitraClip procedure with the pull out of the anterior leaflet during the intervention. The patient underwent cardiopulmonary support and surgical intervention with a good outcome. With this report, we illustrated the etiology and management of this complication.

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        Percutaneous repair or surgery for mitral regurgitation.

        Mitral-valve repair can be accomplished with an investigational procedure that involves the percutaneous implantation of a clip that grasps and approximates the edges of the mitral leaflets at the origin of the regurgitant jet. We randomly assigned 279 patients with moderately severe or severe (grade 3+ or 4+) mitral regurgitation in a 2:1 ratio to undergo either percutaneous repair or conventional surgery for repair or replacement of the mitral valve. The primary composite end point for efficacy was freedom from death, from surgery for mitral-valve dysfunction, and from grade 3+ or 4+ mitral regurgitation at 12 months. The primary safety end point was a composite of major adverse events within 30 days. At 12 months, the rates of the primary end point for efficacy were 55% in the percutaneous-repair group and 73% in the surgery group (P=0.007). The respective rates of the components of the primary end point were as follows: death, 6% in each group; surgery for mitral-valve dysfunction, 20% versus 2%; and grade 3+ or 4+ mitral regurgitation, 21% versus 20%. Major adverse events occurred in 15% of patients in the percutaneous-repair group and 48% of patients in the surgery group at 30 days (P<0.001). At 12 months, both groups had improved left ventricular size, New York Heart Association functional class, and quality-of-life measures, as compared with baseline. Although percutaneous repair was less effective at reducing mitral regurgitation than conventional surgery, the procedure was associated with superior safety and similar improvements in clinical outcomes. (Funded by Abbott Vascular; EVEREST II number, NCT00209274.).
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          Acute and 12-month results with catheter-based mitral valve leaflet repair: the EVEREST II (Endovascular Valve Edge-to-Edge Repair) High Risk Study.

          The EVEREST II (Endovascular Valve Edge-to-Edge Repair) High Risk Study (HRS) assessed the safety and effectiveness of the MitraClip device (Abbott Vascular, Santa Clara, California) in patients with significant mitral regurgitation (MR) at high risk of surgical mortality rate. Patients with severe MR (3 to 4+) at high risk of surgery may benefit from percutaneous mitral leaflet repair, a potentially safer approach to reduce MR. Patients with severe symptomatic MR and an estimated surgical mortality rate of ≥12% were enrolled. A comparator group of patients screened concurrently but not enrolled were identified retrospectively and consented to compare survival in patients treated by standard care. Seventy-eight patients underwent the MitraClip procedure. Their mean age was 77 years, >50% had previous cardiac surgery, and 46 had functional MR and 32 degenerative MR. MitraClip devices were successfully placed in 96% of patients. Protocol-predicted surgical mortality rate in the HRS and concurrent comparator group was 18.2% and 17.4%, respectively, and Society of Thoracic Surgeons calculator estimated mortality rate was 14.2% and 14.9%, respectively. The 30-day procedure-related mortality rate was 7.7% in the HRS and 8.3% in the comparator group (p = NS). The 12-month survival rate was 76% in the HRS and 55% in the concurrent comparator group (p = 0.047). In surviving patients with matched baseline and 12-month data, 78% had an MR grade of ≤2+. Left ventricular end-diastolic volume improved from 172 ml to 140 ml and end-systolic volume improved from 82 ml to 73 ml (both p = 0.001). New York Heart Association functional class improved from III/IV at baseline in 89% to class I/II in 74% (p < 0.0001). Quality of life was improved (Short Form-36 physical component score increased from 32.1 to 36.1 [p = 0.014] and the mental component score from 45.5 to 48.7 [p = 0.065]) at 12 months. The annual rate of hospitalization for congestive heart failure in surviving patients with matched data decreased from 0.59 to 0.32 (p = 0.034). The MitraClip device reduced MR in a majority of patients deemed at high risk of surgery, resulting in improvement in clinical symptoms and significant left ventricular reverse remodeling over 12 months. (Pivotal Study of a Percutaneous Mitral Valve Repair System [EVEREST II]; NCT00209274). Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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            The double-orifice technique in mitral valve repair: a simple solution for complex problems.

            The aim of this study is to report our results with the central double-orifice technique used for the treatment of complex mitral valve lesions. The central double-orifice repair has been used in 260 patients (mean age, 56 +/- 14.3 years) over a period of 7 years. The mechanism responsible for mitral regurgitation was prolapse of both leaflets in 148 patients, prolapse of the anterior leaflet in 68, prolapse of the posterior leaflet with annular calcification or other unfavorable features in 31, and lack of leaflet coaptation for restricted motion or erosion of the free edge in 13. Degenerative disease was the cause of mitral regurgitation in 80.8% of the patients, rheumatic disease was the cause in 9.6%, endocarditis was the cause in 6.1%, and ischemic disease was the cause in 2.3%. Hospital mortality was 0.7%, and the overall survival at 5 years was 94.4% +/- 2.59%. Thirteen patients required a reoperation (2 early postoperatively and 11 late during the follow-up), for an overall freedom from reoperation of 90.0% +/- 3.37% at 5 years. Freedom from reoperation was lower in patients with rheumatic valve disease and in patients who did not undergo an annuloplasty procedure. The effectiveness and durability of the central double-orifice technique were assessed in this study. This type of repair can be a useful addition to the surgical armamentarium in mitral valve reconstruction.

              Author and article information

              [1 ]Department of Cardiology and Pulmology, Charite, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
              Author notes
              [* ]Corresponding author's email address: susanne.rutschow@
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              ScienceOpen Research
              20 October 2014
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              © 2014 S. Rutschow et al.

              This work has been published open access under Creative Commons Attribution License CC BY 4.0 , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at .

              Figures: 4, Tables: 0, References: 6, Pages: 3
              Clinical Case Report


              Valve replacement, MitraClip, Dilated cardiomyopathy


              In the manuscript “Failed MitraClip procedure with pull out of the anterior leaflet ” dr. Rutschow and colleagues report on a patient with severe MR treated with Mitraclip in whom a detachment of the clip from the AML occurred a few minutes after the grasping. The procedure was then stopped and the patient underwent a surgical MV operation.

              The case is interesting as it offers a view of the possible complications during Mitraclip procedure. However it shows some limitations that need to be underlined.

              Major comments.

              The authors state that “The transesophageal echocardiogram conformed severe mitral regurgitation with eccentric lateral jet, posing a combination of degenerative and functional mitral regurgitation” I do not agree with this, in a dilated cardiomyopathy an eccentric jet is found as a consequence of asymmetric tethering. Unless a clear prolapse is demonstrated, this is always a type 3b MR mechanism.

              The screening TEE exam seems quite poor. No data are reported on MV leaflets characteristics and length, and no data are available of annular dimensions. A Mitraclip device is only 16 mm long when its arms are open, therefore in dilated ventricles extreme dilation of MV annulus has to be taken into account as a limiting factor. How long was the AP MV diameter in this case? What about the tethering? Was it symmetric? How deep was the coaptation point?

              Concerning the clip detachment, in my clinical experience this is not a reason for putting the patient on surgical schedule. A second clip can be implanted with good result, I fully agree with dr. Rodrigo Estevez-Loureiro’s comment.

              In our experience even a detached clip can contribute to reduce the leaflet prolapse in type 2 MR.

              2015-05-08 15:04 UTC
              This is an interesting paper reporting an intra-procedural partial clip detachment from the AML. The case is well presented and it seems to me that it was ideal for MitraClip. I would like to stress the importance of confirming that adequate leaflet insertion is mandatory before releasing the clip. However, I disagree with authors that the procedure should be stopped at this point. Usually the placement of a second or third clip can stabilize the first one and achieve an optimal result. Readers must be aware that the presence of partial clip detachment is not an indication for conversion to stander surgery, that, as reported in the case, is associated with high morbidity.
              2014-12-24 11:35 UTC

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