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      Failed MitraClip procedure with pull out of the anterior leaflet

      Clinical Case Report
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            Abstract

            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.

            Main article text

            INTRODUCTION

            Mitral regurgitation in dilated cardiomyopathy is often a functional reason of either ischaemic or idiopathic origin. Furthermore, hybrid forms with functional as well as degenerative mitral regurgitation are described. Persistent severe mitral regurgitation leads to left ventricular and atrial chamber remodeling with poor clinical outcome [1]. In most patients, effective surgical repair of the mitral valve can cause decreasing in the left ventricular volume overload and can lead to reverse left ventricular and left atrial remodeling [2]. Mitral valve repair to reduce the mitral regurgitation by creating a double-orifice was first performed by Alfrieri [3]. Based on this surgical technique, endovascular mitral repair with the use of a clip has been developed [4]. Percutaneous mitral valve repair in edge-to-edge procedure with the MitraClip device has been shown to be associated with good clinical outcomes in patients with high risk for surgery [5]. Furthermore, it demonstrated to be superiorly safe compared with surgical mitral valve repair with similar improvement in clinical outcomes [6].

            CASE REPORT

            We describe a case of a 68-year-old man with severe mitral regurgitation and dilated cardiomyopathy with failed MitraClip procedure. The medical history included inflammatory cardiomyopathy with initial highly reduced ejection fraction (30%) by minor pronounced borderline myocarditis and normal coronary angiogram. With initiating of medical treatment, the left ventricle function was enhanced to 45% but was still persisting atrial fibrillation with unsuccessful cardioversion by severe mitral regurgitation with eccentric lateral jet. Furthermore, he had impaired renal function and a moderately combined lung disease (Euroscore 22%). In cause of dyspnea by minimal stress, we decided to proceed with the procedure of MitraClip.

            The preprocedural echocardiogram revealed minimal dilated left ventricle with end-diastolic dimension of 61 mm and moderate reduced left ventricular function with 45%. We had a bi-atrial dilatation with 305 ml for the left atrium and 144 ml for the right atrium with severe mitral regurgitation and moderate tricuspid regurgitation (Figure 1). The right ventricular systolic pressure was 40 mmHg confirming pulmonary hypertension. The transesophageal echocardiogram conformed severe mitral regurgitation with eccentric lateral jet, posing a combination of degenerative and functional mitral regurgitation (Figure 2). With 3D-echocardiogram, we evaluated the possibility of MitraClip by enough leaflet substance without presentation of severe prolapse or structural disintegrity.

            Figure 1.
            Preprocedural echocardiogram with bi-atrial dilatation.
            Figure 2.
            Preprocedural transesophageal echocardiogram with serve mitral regurgitation.

            The standard procedure was performed with percutaneous femoral venous transseptal access. The clip was aligned above the mitral valve, approved with 3D-echocardiogram, before grasping and coapting the leaflets. The grasp of the leaflets was easy and unspectacular; with the second try of grasping, we demonstrated a reduction of the mitral regurgitation from severe to minimal, with remaining jet lateral of the clip. The verification of the leaflet insertion confirmed enough stuff of the posterior leaflet as well as of the anterior leaflet in the clip. By waiting 15–20 minutes after grasping and furthermore constant well-fitting clip, we decided a two-clip procedure to reduce the remaining lateral jet. After preparation of the second device transesophageal echocardiogram, it revealed a pull out of the anterior leaflet. The clip was only attached on the posterior leaflet. Out of the clip on the anterior side, we see approximately 8 mm stuff pull out of the anterior leaflet (Figure 3, Supplementary Video 1).

            Figure 3.
            Intraprocedural transesophageal echocardiogram with pull out of the anterior leaflet.
            Supplementary Video 1.
            Trans-esophageal three chamber view with pull out of the anterior leaflet.

            The procedure was discontinued and the anesthesia ended. The patient was awake and hemodynamic steady. Two days later, he received a standard median sternotomy with mitral valve replacement of a biological valve Labcor 31 mm (Figure 4). The postoperative process was prolonged in case of acute renal failure, sick sinus syndrome with the necessity of a permanent pacemaker, and infectious complications including a serve clostridia colitis. After six weeks of hospital stay, we could discharge the patient in rehabilitation.

            Figure 4.
            Postoperative echocardiogram with mitral valve replacement (Labcor 31 mm).

            Three months after mitral valve replacement in our outpatient department, the patient was obviously improved clinically. Echocardiogram revealed a good function of the mitral valve replacement without any mitral regurgitation by constant moderate tricuspid regurgitation.

            DISCUSSION

            Mitral clipping is an attractive alternative treatment of severe mitral regurgitation compared with cardiac surgery in patients with moderate and high risk for surgery. Described before is the dissolve of the posterior or anterior leaflet after insufficient leaflet insertion. This was the first report which shows the pull out of the anterior leaflet during the procedure. Beside the functional mitral regurgitation in cause of dilatation of the annulus, the MitraClip procedure is also described as effective and safe in degenerative mitral regurgitation. In spite of these observations, it might be necessary to have a careful analysis of the structural integrity of the leaflets in order to guard this situation, particularly in case of the missing possibility of mitral valve repair after MitraClip procedure as the first instance.

            References

            1. , , , , . Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol. 2003;91(5):538–43. [Cross Ref]

            2. , , , , , , , . Recurrence of mitral regurgitation parallels the absence of left ventricular reverse remodeling after mitral repair in advanced dilated cardiomyopathy. Ann Thorac Surg. 2008;85(3):932–39. [Cross Ref]

            3. , , , , , , . The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg. 2001;122(4):674–81. [Cross Ref]

            4. , , , , , , , . Endovascular edge-to-edge mitral valve repair: short-term results in a porcine model. Circulation. 2003;108(16):1990–93. [Cross Ref]

            5. , , , , , , , , , , , , , , , , , . Acute and 12 month results with catheter-based mitral valve leaflet repair: the EVEREST II (Endovascular Valve Edge to Edge Repair) high risk study. J Am Coll Cardiol. 2012;59(2):130–39. [Cross Ref]

            6. , , , , , , , , , , , , , , , , . EVEREST II Investigators. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011;364(15):1395–406. [Cross Ref]

            Competing Interests

            The authors declare no competing interests.

            Publishing Notes

            © 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 www.scienceopen.com.

            Author and article information

            Contributors
            (View ORCID Profile)
            Journal
            SOR-MED
            ScienceOpen Research
            ScienceOpen
            2199-1006
            20 October 2014
            : 0 (ID: 102421ec-ab2b-4b95-97e2-23e069972baa )
            : 0
            : 1-3
            Affiliations
            [1 ]Department of Cardiology and Pulmology, Charite, Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlin, Germany
            Author notes
            [* ]Corresponding author's email address: susanne.rutschow@ 123456charite.de
            Article
            1954:XE
            10.14293/S2199-1006.1.SOR-MED.AQBXG3.v1
            102421ec-ab2b-4b95-97e2-23e069972baa
            © 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 www.scienceopen.com .

            Page count
            Figures: 4, Tables: 0, References: 6, Pages: 3
            Product
            Categories
            Clinical Case Report

            Medicine

            Valve replacement, Dilated cardiomyopathy, MitraClip

            Comments

            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
            +1
            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
            +1

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