Abstract
Functional mitral regurgitation (MR) is common in patients with ischemic cardiomyopathy. We present a case of an 83-year-old patient with ischemic heart disease and ischemic cardiomyopathy, who was repeatedly admitted for pulmonary edema and underwent a percutaneous trans-septal MitraClip procedure. During coronary angiography, a severe left main stenosis was demonstrated. Treatment included both percutaneous coronary intervention and the implantation of two MitraClip devices, with very good results. We believe that this case illustrates the need for comprehensive assessment of ischemia in patients with functional MR.
1
Introduction
In patients with heart failure, mitral regurgitation is very common, even in the absence of structural mitral valve disease, due to secondary structural changes of the ventricle and mitral annulus . Robbins et al. reported a prevalence of 59% of moderate or greater MR in patients with systolic failure. In many of these patients, surgery carries a high risk of mortality and morbidity and select patients can be referred for a transcatheter alternative for mitral valve edge-to-edge repair using a clip implant . We report a case of a patient with severe functional MR and concomitant coronary artery disease which highlights the need for a comprehensive evaluation in these often critically ill patients.
2
Case report
The patient is an 83-year-old man with a history of multiple cardiovascular risk factors (diabetes mellitus, hypertension and dyslipidemia), chronic renal failure, chronic atrial fibrillation and ischemic heart disease, having suffered an inferior myocardial infarction 30 years previously. He subsequently developed ischemic cardiomyopathy with moderate left ventricular systolic dysfunction and severe functional mitral regurgitation. More recently he suffered from repeated exacerbations of heart failure deteriorating to New York Heart Association functional class III-IV and had required recurrent hospital admissions for treatment of respiratory failure and pulmonary edema despite optimization of medical therapy, including β-blockers, ACE inhibitors, spironolactone and diuretics. The patient was considered to have stable ischemic heart disease, having not suffered from angina in recent years. A non-invasive stress test had been performed many years ago reporting no evidence of ischemia. The treating physician felt that the patient is stable and that his symptoms are related to his ventricular dysfunction and valvular disease, therefore deciding not to further investigate for coronary artery disease.
The patient was considered for a MitraClip procedure and a transesophageal echocardiogram (TEE) demonstrated severe MR with adequate anatomical parameters for clip implantation, including the lack of stenosis or calcification, a leaflet coaptation length of 5 mm and a main jet around the A2/P2 portion of the mitral valve leaflets.
During the procedure a coronary angiography was performed prior to clip implantation, demonstrating severe distal left main coronary artery disease ( Fig. 1 , arrow). Considering the patient’s history and current presentation it was decided to treat the narrowing ( Fig. 1 ). Unprotected left main stenting was performed using a 7F guiding catheter, floppy wire placed into the left anterior descending coronary artery, pre-dilation of the lesion using a 3.0 × 10-mm cutting balloon followed immediately by implantation of a single Resolute (Medtronic, MN, USA) drug-eluting stent (DES) measured at 4.0 × 12 mm in the left main and into the origin of the left anterior descending artery. The angiographic result was optimal without complications and/or compromise of the left circumflex coronary artery origin. Unfractionated heparin was given as anti-coagulation at 50 U/kg (3500 U) during the PCI to an ACT of 225 s. Thus, the trans-septal puncture was executed while the patient is “on heparin” treatment and using TEE guidance without any complications.
This was followed by implantation of two MitraClip devices, with a reduction of the MR to grade 1 + ( Fig. 2 ). There were no immediate complications. The Doppler gradient across the mitral valve remained low (3 mm Hg) following clip implantation.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
