An 85-year-old man with severe aortic stenosis underwent transcatheter, transapical placement of a 26 mm Sapien S3 prosthesis. Following aortic valve replacement, new, severe mitral regurgitation (MR) occurred due to rupture of the anterolateral papillary muscle. Due to his prohibitive surgical risk, he underwent emergent transcatheter repair with MitraClip (Abbott Vascular, Santa Clara, CA).
A, Transesophageal echocardiography (TEE) demonstrates severe MR (arrowhead). Imaging with TEE shows the ruptured papillary muscle in the left atrium in systole (B, arrow) and in the left ventricle in diastole (C, arrow). D, A relatively low mitral height (4.0 cm) was chosen for the transseptal puncture given the lateral location of the mitral pathology. E, With slight counterclockwise rotation, the clip arms are aligned perpendicular to the lateral mitral coaptation plane (arrow). F, With introduction of the clip arms into the left ventricle (arrows), movement of the papillary muscle in and out of the left atrium continues (arrowheads). G, With appropriate timing, the grippers are dropped to grasp the mitral leaflets to trap the ruptured papillary muscle in the left ventricle (arrowhead) in order to maximize reduction in MR as seen in this left ventricular outflow tract view. H, Bi-commissural imaging also shows the papillary muscle trapped in the left ventricle (arrowhead). I, With complete closure of the clip arms, the diastolic mitral gradient is prohibitively high at 19 mm Hg. J, With opening of the clip arms to 30 degrees, the mitral gradient is reduced to 7 mm Hg. K and L, Multiple views show only mild residual MR with the clip arms open at 30 degrees (arrowheads). M, Fluoroscopy shows the 30-degree final arm angle for the clip (arrowhead). N, The final arm angle is established, followed by release of the clip (arrowhead).
Ao Ascending aorta; Av, aortic valve prosthesis; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; SGC, steerable guide catheter.