Percutaneous edge-to-edge mitral valve repair can be performed safely, and reductions in mitral regurgitation can be achieved in a significant proportion of patients. However, complications can arise in a minority of patients. The authors report three cases in which complications of percutaneous mitral valve repair were documented by real-time three-dimensional transesophageal echocardiography. This new imaging technique provides real-time, easily understandable images of valve anatomy and the percutaneous mitral valve repair procedure, which helps guide the decision-making process.
Mitral valve surgery (i.e., valve repair or replacement) is the only treatment with proven efficacy for severe mitral regurgitation (MR). Percutaneous mitral valve repair (pMVR) is a novel approach currently under clinical scrutiny. Multiple different techniques of pMVR have been evaluated over the past few years. Among them, the edge-to-edge pMVR technique using the MitraClip (Abbott Laboratories, Abbott Park, IL) system has provided encouraging preliminary results in the Endovascular Valve Edge-to-Edge Repair Study. This modality may provide a valuable alternative to mitral valve surgery, especially in critically ill patients at high surgical risk. It is applicable to MR of functional and degenerative origins, which account for approximately two thirds and one third of cases at our institution, respectively. The success of edge-to-edge pMVR using the MitraClip system requires optimal echocardiographic guidance. Here we report echocardiographic findings in three patients treated using this modality, illustrating three different complications that can arise during the procedure.
Case Presentations
Case 1
A 67-year-old man with a history of dilated cardiomyopathy and previous cardiac resynchronization therapy device implantation underwent edge-to-edge pMVR because of severe functional MR. The clip was correctly implanted, and the procedure was monitored by two-dimensional (2D) and real-time three-dimensional (3D) transesophageal echocardiography. However, a few days later, detachment of the clip from the posterior mitral leaflet (PML), resulting in severe MR, was documented on routine transthoracic echocardiography. Review of the 3D images acquired during the procedure showed that the amount of tissue of the anterior mitral leaflet (AML) grasped by the clip was quite large ( Figure 1 A, white arrows ), while the PML was grasped near its free margin ( Figure 1 A, black arrows ). We assumed that this was the reason for the detachment. Because of severe MR, the implantation of a second clip was planned. Figure 1 B shows the partial detachment of the clip anchored at the AML, with severe MR. Under real-time 3D transesophageal echocardiographic guidance, a second clip was inserted close to the first one ( Figure 1 C), with a satisfying final result.
Case 2
An 82-year-old man with a history of coronary artery bypass graft surgery and congestive heart failure underwent pMVR because of severe functional ischemic MR. As demonstrated by real-time 3D TEE, MR was caused by a prolapse of the central and lateral segment of the AML ( Figure 2 A, asterisk ), associated with a restrictive motion of the PML due to previous myocardial infarction, resulting in a lateral regurgitant orifice ( Figure 2 B). The alignment of the two arms of the MitraClip device to the coaptation line of the leaflets was guided exclusively by real-time 3D TEE and proved to be particularly difficult because of the lateral location of the defect ( Figure 2 C). After multiple failed attempts to grasp the PML, an unexpected worsening of MR caused by rupture of tendinous chords was observed ( Figure 2 D). The patient underwent immediate surgical valve replacement. Histologic examination of the leaflet showed an extensive traumatic hemorrhage within the valve tissue.
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