Fig. 12.1
Left ventricle volumes and ejection fraction (a) and left ventricle diameters (b). A two-dimensional transthoracic echocardiography at baseline shows a postinfarction dilated cardiomyopathy with severe left ventricle dysfunction and dilation
Fig. 12.2
Mitral regurgitation. Color Doppler examination reveals severe mitral regurgitation (4+) with a central jet extending to the atrial roof
Fig. 12.3
Baseline coaptation. Baseline echocardiography shows complete absence of leaflet coaptation
There was no indication to cardiac resynchronization therapy (CRT), therefore a monocameral ICD was implanted on August 2010.
No symptoms occurred until July 2011 when the patient was admitted at our department due to acute heart failure.
Although an optimal medical therapy achievement, in the following months, a functional NYHA class III–IV persisted and hospitalizations due to acute heart failure occurred. In particular, five hospitalizations for a total of 78 days of in-hospital stay were counted between July 2011 and February 2012.
The right cardiac catheterization confirmed a severe postcapillary pulmonary hypertension (systolic and diastolic pulmonary pressure of 80 and 43 mmHg, respectively; capillary wedge pressure of 51 mmHg) and a severe reduction of cardiac output (1.8 l/min/m2).
A severe disorder of functional status was evident at the cardiopulmonary test with a peak VO2 of 7.9 mL/min/Kg and a VE/VCO2 slope of 56. The distance walked at the 6-min walking test (6MWT) was 348 m.
It was not possible to include the patient in waiting list for heart transplantation owing to the history of cocaine abuse and previous stroke. Because of the high surgical risk, the Heart Team decided, on February 2012, to consider the percutaneous mitral valve repair with MitraClip system despite the complete absence of leaflet coaptation.
12.2 Preparation to MitraClip Procedure
Pharmacological agents and mechanical support were used to restore the leaflet coaptation allowing MitraClip therapy.
The patient was treated with intravenous diuretic and vasodilator drugs in order to reduce the left ventricle preload. In particular, 500 mg/day of furosemide and 2 ml/h of nitrate were infused for 48 h. However, no improvement of leaflet coaptation was observed.
The second step was the administration of an inotropic support (enoximone 5γ/Kg/min) in order to modify the ventricle geometry increasing the contractility. Nevertheless, after 24 h, it was still not enough.
As a last step, an intra-aortic balloon pump (IABP) was implanted in order to further decrease left ventricle pre- and post-load; 24 h later, the echocardiography showed a coaptation depth of 20 mm and a coaptation length less than 2 mm but enough to try a leaflet grasping with the MitraClip device.
12.3 MitraClip Procedure
The procedure was performed with IABP and enoximone infusion.
At the transesophageal echocardiography, after anesthesia induction, a coaptation length of 2 mm and a coaptation depth of 18 mm were detected (Fig. 12.4 and Video 12.3).
Fig. 12.4
Coaptation after drugs, IABP, and anesthesia. A sufficient coaptation length is detected at the TEE performed after enoximone, IABP placement, and anesthesia induction
A first clip was implanted in central position, between A2 and P2 leaflets, resulting in a moderate regurgitation with a mitral valve area >4 cm2 and a mean trans-valve gradient of 1 mmHg (Fig. 12.5). Therefore, a second clip was placed, very close and lateral to the first one, with an excellent final result: trivial MR, mean gradient 2 mmHg, valve area about 3 cm2 (Fig. 12.6), and normalization of S/D ratio on pulmonary veins.
Fig. 12.5
Results after first clip placement. The fluoroscopic snapshots show the successful implantation of the first clip (a) with a residual moderate mitral regurgitation (b), a low mean gradient (c), and a large double mitral orifice (d) at the echocardiography
Fig. 12.6
Final result. The fluoroscopic snapshots show the successful implantation of the second clip very close and lateral to the first one (a) with a residual trivial mitral regurgitation (b) and absence of mitral stenosis (c, d) at the echocardiography
No complication occurred during the procedure. The patient was weaned from IABP and pharmacological supports at 2 and 6 days, respectively. He was discharged 9 days after MitraClip implantation on functional NYHA class II and with a mild MR.
12.4 Follow-Up
The clinical, echocardiographic, and hemodynamic parameters detected during the follow-up and compared with the baseline are displayed in Table 12.1.
Table 12.1
Clinical, echocardiographic, and hemodynamic parameters at baseline and follow-up
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