An 84-year-old man was referred for treatment of symptomatic, severe mitral regurgitation (MR), in the setting of multiple, high-risk morbidities (for example, prior stroke, chronic renal failure, and frailty). His MR was primarily due to a flail posterior leaflet, and he underwent transcatheter repair with MitraClip (Abbott Vascular, Santa Clara, CA).
A, Transesophageal echocardiogram showing a flail posterior mitral leaflet involving the P2 segment (arrowhead). B, The flail segment is also easily visible on 3-dimensional echocardiography of mitral valve (MV) in a surgeon’s view (arrowhead). C, A single clip (arrowhead) is placed to target the flail portion, leading to apposition of the A2-P2 segments of the MV. D, Residual MR is present after placement of clip despite treatment of the flail segment. On some echocardiography views, the residual MR appears to be more than mild (arrowhead). E and F, Prior to placing a second clip, the left atrial pressures are examined. In our practice, the left atrial pressure is examined at a systolic blood pressure of 150 mm Hg to gain insight into the dynamic nature of the MR and volume overload prior to MitraClip therapy. This hemodyanamic study frequently requires administration of phenylephrine. In this patient, the mean left atrial pressure was 38 mm Hg at a systolic blood pressure of 147 mm Hg (E). Following placement of the clip, re-examination of the hemodynamics shows that the mean left atrial pressure is now only 13 mm Hg at a systolic blood pressure of 152 mm Hg (F). This finding demonstrates that the residual MR is not associated with significant left atrial hypertension at rest or during dynamic maneuvers. A second clip therefore was not placed, and the patient did well with no symptoms in follow-up.
Ao, Ascending aorta; LA, left atrium; LV, left ventricle.