Abstract
Background
The MitraClip procedure can be an alternative treatment option for patients with high surgical risk for whom surgical treatment is contraindicated. Patients with prosthetic material have an increased risk for infective endocarditis.
Hypothesis
Incidence, treatment and outcome of patients with endocarditis after interventional mitral valve repair are not known.
Methods
We searched for articles using PubMed using the terms “interventional mitral valve repair”, “mitraclip” and “endocarditis”. We have also searched for case reports in major congresses. Furthermore, we report two cases.
Results
Four cases of IE after MitraClip were found in addition to our cases. The leading cause is a bacterial infection, typically with staphylococcal bacteria. Approximately two thirds of these patients underwent surgery. Short-term outcome seems to be reasonable for these patients. During the early postoperative period and if Staphylococcus aureus can be cultivated mortality seems to be significantly elevated.
Conclusion
IE after MitraClip procedure is a dilemma. While surgical bail-out seems to be the favorable treatment option, patients were rejected conventional surgery in first place due to their high operative risk. Best treatment recommendation must be made on an individual basis. Predisposing factors should be conscientiously addressed prior to the procedure.
Highlights
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The interventional repair of the mitral valve is gaining in importance.
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The incidence of infective endocartitis after MitraClip is low but its relevance due to its high mortality rate is high.
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We aimed to review the literature for the incidence, treatment and outcome of IE after MitraClip procedure.
1
Introduction
Mitral valve regurgitation is the second most common heart valve disorder . In general population, the prevalence is 1–2% but it is as high as 10% in patients older than 75 years . Surgical mitral valve repair (SVR) is considered to be the standard treatment . There are some patients with high surgical risk, however, for whom SVR is contraindicated. The interventional repair with the MitraClip system (Abbott Vascular, Santa Clara, CA, USA) can be an alternative treatment option. Both the EVEREST II trial and the ACCESS EU registry demonstrated the safety and efficacy of the device . The most common complications are short-term periprocedural. Infective endocarditis (IE) after MitraClip procedure is rare but will increase with spread of procedure. We therefore aimed to review the literature for the incidence, treatment and outcome of IE after MitraClip procedure.
2
Methods
We searched for articles using PubMed database as well as bibliographical cross-references of all articles using the terms “interventional mitral valve repair”, “mitraclip” and “endocarditis”. Search results included six abstracts, however, only two of them actually discussed active endocarditis. Four of the articles had to be disregarded as they studied histopathological findings, e.g., in porcine model, or reviewed the procedure itself or its aftercare. We have also searched for these topics as case reports in major congresses. This included the congresses of the European Society of Cardiology and EuroPCR, the American College of Cardiology, Trans-Catheter Cardiovascular Therapeutics, and the American Heart Association. Furthermore, we report two cases of our own clinic. The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
2
Methods
We searched for articles using PubMed database as well as bibliographical cross-references of all articles using the terms “interventional mitral valve repair”, “mitraclip” and “endocarditis”. Search results included six abstracts, however, only two of them actually discussed active endocarditis. Four of the articles had to be disregarded as they studied histopathological findings, e.g., in porcine model, or reviewed the procedure itself or its aftercare. We have also searched for these topics as case reports in major congresses. This included the congresses of the European Society of Cardiology and EuroPCR, the American College of Cardiology, Trans-Catheter Cardiovascular Therapeutics, and the American Heart Association. Furthermore, we report two cases of our own clinic. The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
3
Results
To our knowledge, four cases of IE after interventional repair of mitral valve regurgitation have been published ( Table 1 ). The “” first patient was successfully treated with three clips in 2011 . He was admitted three years after the procedure due to fever. Blood cultures were positive for S. epidermidis . The patient underwent surgery for replacement of a prosthetic valve and explantation of an internal cardioverter defibrillator (ICD). He was alive on day 52 after surgery. The case report did not provide further information on the clinical course or antibiotic regimen. The second case was a patient who had ruptured chordae with adherent material on the clip and presented with fever 5 weeks after the interventional repair . She underwent surgery and the 1-year follow-up was reported as being uneventful. The third patient underwent a MitraClip procedure due to a high surgical risk with a logistic EuroSCORE of 30.4% . The patient was readmitted 30 days later with fever and dyspnea (NYHA III). Blood cultures were positive for Staphylococcus aureus and an echocardiogram demonstrated recurrence of severe MR. An antibiotic regimen consisting of vancomycin, gentamicin and rifampicin was initiated. After heart team consultation, surgery was performed despite the increased risk (logistic EuroSCORE 56.8%, EuroSCORE II 25.3%). The patient was discharged and prescribed antibiotics for six more weeks. No further follow-up data were reported. The fourth patient presented with dyspnea and a weak popliteal pulse 14 months after MitraClip implantation . CT angiography confirmed a blocked A. poplitea sinistra. Echocardiography demonstrated a highly mobile mass attached to the mitral valve. Blood cultures were positive for alpha-hemolytic streptococcus and antibiotic therapy was initiated. The patient remains under observation with serial echocardiograms. No further follow-up data were reported.
| No. | Reference | Age | Sex | Major comorbidities | No. of clips | Time after clip | Predisposing factors | Pathogen | Treatment | Outcome |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | Saito et al. | 52 | M | Chronic kidney disease Diabetes mellitus | 3 | 3 years | Dialysis | St. epidermidis | Surgery | Alive after 52 days |
| 2 | Maznikoski et al. | Unknown | F | Unknown | Unknown | 5 weeks | Unknown | Unknown | Surgery | Alive after 1 year |
| 3 | Frerker et al. | 88 | M | Chronic kidney disease stage III Pulmonary hypertension | 2 | 30 days | Unknown | S. aureus | Surgery | Alive after 15 days |
| 4 | Vazir et al. | 67 | M | Coronary heart disease | 1 | 14 months | Aortic valve prothesis | Alpha-hemolytic streptococcus | Conservative | No follow up |
| 5 | Case 1 | 83 | F | COPD Stroke | 1 | 14 days | History of erysipelas | S. aureus | Conservative | Death after 2 weeks |
| 6 | Case 2 | 76 | F | Stroke | 2 | 22 days | Peripheral venous catheter | S. aureus | Surgery | Death after 31 days |
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