A 90-year-old woman was referred for treatment of symptomatic mitral regurgitation (MR) with MitraClip (Abbott Vascular, Santa Clara, CA). Her medical history was significant for chronic renal insufficiency (estimated glomerular filtration rate, 32 cc/min) and long-standing hypertension.
A, Transesophageal echocardiography (TEE) demonstrated a torn chord involving the posterior mitral leaflet (arrow), with significant posterior mitral annular calcification (MAC, arrowhead). B, The MAC, which is present along much of the posterior annulus, is visible on 3-dimensional echocardiography in a surgeon’s view (arrowheads). The mean mitral gradient was only 1 mm Hg (not shown). C, To maximize the ability to maneuver the steerable sleeve of the clip delivery system around the MAC, the most posterior location possible is chosen for the transseptal puncture. This posterior location is best seen on short-axis view of the aortic valve with TEE (arrowhead). The height of the puncture to the mitral valve was 4.7 cm (not shown). D, The steerable sleeve is positioned considerably posterior (arrowhead) to the aorta, and the clip arm is able to be placed between the MAC and the posterior mitral leaflet. E, Following clip deployment, the flail segment is treated and the residual MR is mild. F, TEE with 3-dimensional imaging showing the tissue bridge created with clip deployment (arrow).
Ao, Ascending aorta; LA, left atrium; LV, left ventricle; RA, right atrium.