Abstract
Functional mitral regurgitation (FMR) is common in severe heart failure. Medical therapy is the standard of care since the role of surgery is less established. Various trans-catheter percutaneous techniques may avoid the risks of surgery; such as edge-to-edge repair using MitraClip system (Abbott Vascular, Illinois, USA) and CARILLON® Mitral Contour System® (Model XE2; Cardiac Dimensions., Kirkland, WA, USA). We present the case of a 41-year-old man with severe dilated cardiomyopathy, NYHA IIIb, and grade 3 MR. Due to high surgical risk (logistic EuroScore 35.1) he initially underwent single MitraClip insertion with significant echocardiographic and clinical improvement (MR reduced from 3+ to 1+, NYHA classes III to II). Fifteen months later, he developed heart failure symptoms due to recurrence of severe MR and was retreated with percutaneous CARILLON® Mitral Contour System® with resolution of MR and doing well at nine-month follow-up. A combined approach of MitraClip followed by percutaneous mitral annuloplasty demonstrated clinically meaningful reduction of MR and resulted in significant symptomatic improvement for up to 6 months. Follow-up for longer period is warranted to ensure sustained favorable outcome.
Highlights
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MitraClip has attained CE mark and recent FDA approval for treatment of patients with significant MR and those who are at high risk for surgical correction.
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CARILLON mitral contour system is a promising technology for treatment of FMR among patients with dilated Cardiomyopathy.
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Combination of both technologies can significantly enhance the chances of successfully reducing MR and sustaining the benefit over longer periods among patients with dilated cardiomyopathy
1
Introduction
Increasing degree of functional mitral regurgitation (FMR) contributes to increasing morbidity and mortality. The etiology of FMR among patients with advanced systolic heart failure is related to multiple mechanisms such as mitral annular dilation, papillary muscle dysfunction or chordal tethering. At present, the optimal management strategy for FMR is not clearly defined in guidelines.
Over the past 5 years, a variety of trans-catheter techniques have emerged for the percutaneous treatment of mitral regurgitation (MR), the most studied being the MitraClip (Abbott Vascular, Abbott Park, Illinois, USA; formerly manufactured by Evalve Inc., Menlo Park, California, USA). Two year results from EVEREST II trial showed that the percutaneous repair of the mitral valve was less effective in reducing mitral regurgitation when compared to conventional surgery but had superior safety profile and similar improvements in clinical outcomes . In addition, numerous registries have reported favorable outcomes after MitraClip implantation . Percutaneous mitral annuloplasty (CARILLON® Mitral Contour System® (Model XE2); Cardiac Dimensions, Inc., Kirkland, WA, USA) uses another indirect approach where the device is introduced via the coronary sinus to encircle around two thirds of the mitral annulus which creates tension and constricts the mitral annulus. The AMADEUS study showed that the CARILLON, Mitral Contour System can be used in patients with FMR and significant heart failure with a low rate of major adverse events and improved quality of life and exercise tolerance . In addition, two safety device trials; TITAN I and II showed that the Carillon device was safe and resulted in clinical significant reductions in FMR which was associated with marked symptomatic and functional improvement .
We report a patient with idiopathic dilated cardiomyopathy and severe FMR who was initially treated with MitraClip with satisfactory clinical outcome. However, he developed functional deterioration within fifteen months and underwent CARILLION implantation. Our case describes a novel combined approach, with few published cases to date and demonstrates the feasibility and clinical utility of this method of treatment.
2
Case report
A 41-year-old man with dilated cardiomyopathy presented with severe exertional dyspnea and pulmonary edema. His echocardiogram showed left ventricular ejection fraction (LV EF) of 20%, left ventricular end diastolic dimension (LVEDD) of 63 mm, left atrial (LA) size of 61 mm and an eccentric grade of 3+ MR. The patient’s Logistic EuroScore was 35.1. His case was discussed at the Heart team meeting and in view of high expected peri-operative morbidity and mortality; he was offered treatment using edge-to edge MitraClip system. Initial trans-esophageal echocardiogram (TEE) ( Fig. 1 ) showed a 3+ MR central jet emanating mainly between P2 and A2 which occupied 38% of left atrial (LA) size with proximal isovelocity surface area measuring 0.4 cm, vena contracta measuring 4 mm and mitral annulus diameter measuring 38 mm. On June 2014, he underwent successful deployment of a single MitraClip between A2 and P2. Immediate post-MitraClip echocardiogram revealed only trace residual MR with acceptable MV gradients; peak pressure gradient was 4 mm Hg and mean pressure gradient was 1.5 mm Hg. Patient was treated with aspirin 325 mg daily for 6 months and clopidogrel 75 mg daily for 30 days after the procedure. On subsequent follow-up the patient reported significant functional improvement to NYHA class II.
Despite initial symptomatic relief, he presented fifteen months later with recurrence of increasing exercise intolerance and easy fatigability, paroxysmal nocturnal dyspnea and orthopnea. Repeat TEE confirmed a well-positioned MitraClip between A2 and P2 scallops with recurrence of Grade 3+ MR emanating around the clip from both sides. The MR jet was more prominent on the medial side compared to the lateral side. His LVEDD increased to 65 mm, LA size increased to 69 mm and mitral annulus diameter increased to 42 mm as a result of natural progression of his dilated cardiomyopathy with time. At presentation, his NYHA class was 4, his logistic EuroScore was 22.8, he failed optimal medical therapy and was deemed high risk for surgery. After repeated heart team meetings and a detailed discussion with the patient, we decided to undertake a percutaneous mitral annuloplasty.
A coronary arteriogram was performed to assess for underlying coronary arteries and the implant procedure was done under general anesthesia to facilitate intra-procedural TEE ( Fig. 2 ). The venous phase of the arteriogram served as a roadmap for coronary sinus canulation. Due to the close proximity of the circumflex artery to the great cardiac vein and to prevent impingement of the circumflex artery post-CARILLON implantation, we performed arteriogram throughout the deployment sequence. In addition, before the implant was decoupled, coronary arteriography was repeated to confirm that coronary flow was not compromised ( Fig. 3 ). Post-CARILLON implantation MR reduced to Grade 1, peak pressure gradient became 6 mm Hg and mean pressure gradient was 2.5 mm Hg ( Fig. 4 ). His symptoms improved to NYHA II. On nine month post-CARILLON follow-up, our patient was doing well with no further recurrence of MR apart from residual 1+ MR, improvement in overall function to NYHA II, 6 min walk test from 307 ± 87 m at baseline to 403 ± 137 m ( P < 0.001) and quality of life as measured by the Kansas City Cardiomyopathy Questionnaire .
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