A 67-year-old man with severe symptoms from mitral regurgitation (MR) secondary to Barlow’s disease was evaluated. On transesophageal echocardiography, there was a flail leaflet (A, arrowhead) with severe MR (B, arrows). Because of impaired mobility due to Parkinson’s disease, our heart team deemed him to be extreme surgical risk, and we elected to proceed with transcatheter mitral valve (MV) repair using the MitraClip system (Abbott Vascular, Santa Clara, CA). There was a flail height of ~1.0 cm, and we decided on gaining extra “height” by performing a transseptal puncture ~4.5 cm above the mitral annulus. With multiple flailing scallops, we knew that three clips would be required, and we started with our first clip at the A1-P1 scallops as this area had the shortest flail height. Despite numerous grasp attempts, the anterior leaflet kept “knuckling” into the grippers, preventing us from getting an adequate leaflet insertion. Therefore, we inserted a transvenous temporary pacemaker. With rapid ventricular pacing (180 bpm), the leaflet excursion was minimized, and we were able to grasp the leaflets with the clip (C and D, arrows). After this grasp, the MR remained severe medial to the first clip (E, arrow). We grasped the A2-P2 segments with a second clip using rapid ventricular pacing (F, arrowhead), leading to a reduction in MR to moderate. After examining the MV gradient (2 mm Hg), we then implanted a third clip to treat the prolapse of the A3-P3 segments (G, arrowheads). The MR was reduced to mild, and the final MV gradient was only 3 mm Hg (H, arrowhead). The patient’s cardiac symptoms were significantly improved (New York Heart Association class I), although the patient remains limited by his Parkinson’s disease. At one year of follow-up, all the clips remain on the leaflets with a residual MR of ≤ 2+.
A, Anterior; L, lateral; LA, left atrium; LV, left ventricle; LVOT, left ventricular outflow tract; M, medial; P, posterior; TPM, temporary pacemaker; SGC, steerable guide catheter.
