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Mitral annuloplasty ring and two MitraClip® devices: Quintuple diastolic filling orifice
International Journal of Cardiology 203 (2016) 182–183
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Mitral annuloplasty ring and two MitraClip® devices: Quintuple diastolic filling orifice Fernando Carrasco-Chinchilla, Isabel Rodríguez-Bailón, Juan Alonso Briales ⁎, Antonio Domínguez-Franco, Antonio Muñoz-García, Eduardo deTeresa-Galván, José María Hernández-García Virgen de la Victoria Hospital, Spain
a r t i c l e
i n f o
Article history: Received 5 October 2015 Accepted 13 October 2015 Available online 23 October 2015 Keywords: Mitral regurgitation Mitral annuloplasty Mitraclip
The MitraClip® system allows offering of treatment to patients with mitral regurgitation and high surgical risk [1]. The growing experience of centers can overcome the initial anatomical restrictions evaluated by echocardiography and treat increasingly complex cases [2,3]. A 54 years old male patient affected by three vessel ischemic heart disease with mild systolic dysfunction and secondary moderate mitral regurgitation was treated by cardiac surgery (coronary artery bypass grafting with concomitant reductive annuloplasty ring implantation). After six years, patient presented heart failure and had developed severe ventricular dysfunction and functional severe mitral regurgitation. The
Fig. 1. A: three-dimensional echocardiography showing annuloplasty ring and MitraClip® devices (*,*). Periannular filling holes are noted. B: ColorDoppler with quintuple-orifice of diastolic filling. C: Systolic image showing mild to moderate mitral regurgitation. ⁎ Corresponding author at: Virgen de la Victoria Hospital, Campus Universitario Teatinos s/n, Málaga, Spain. E-mail address: [email protected] (J.A. Briales).
http://dx.doi.org/10.1016/j.ijcard.2015.10.114 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Correspondence
triple coronary bypass was patent. After being discussed by the heart team, we decided to try to repair the valve percutaneously with the MitraClip® device. The annuloplasty ring can makethe device implantation difficult: the antero-posterior diameter of the ring is smaller than that of the opened clip, so it was necessary to introduce the device closed through the ring. On the other hand, poor echocardiographic image quality can be obtained during the procedure due to acoustic shadows produced by the ring (mainly for the grasping). Implantation of a single MitraClip® device was finally performed with good clinical and echocardiographic results (moderate regurgitation and no stenosis). But nevertheless, one year later the patient again presented heart failure refractory to medical treatment and severe mitral regurgitation. Exhaustive evaluation by transthoracic and transesophageal echocardiographies [4] can identify the mechanism of mitral regurgitation and assess whether the problem can be solved with a new device [5]. Echocardiogram shows the MitraClip® was properly attached to the leaflets, and no perforation or other damage leaflets were noted, however a new regurgitation jet had appeared near the device, due to restrictive movement of the posterior leaflet.After debating with the heart team, a new device implantation was indicated. Mitral stenosis could be the main handicap for a new MitraClip® implantation. The second device was successfully implanted close to the first MitraClip®, achieving significant reduction of mitral regurgitation. In the three-dimensional echocardiographic image quintuple diastolic filling orifice was noted (Fig. 1A, B). Two orifices were located near the MitraClip® devices and inside the annuloplasty ring (red arrows). Three additional orifices (green arrows) were situated outside the ring, with important contribution to the left ventricular filling and
183
without systolic flow (no periprosthetic regurgitation (Fig. 1C, video)). Periannular holes with isolated diastolic flow had been noted previously when we performed the first MitraClip® implantation. This is the first reported case of successful implantation of second MitraClip® in patient with previous MitraClip® and mitral annuloplasty ring. Existence of peri-annular filling holes probably contributes to the absence of stenosis. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.10.114. Conflict of interest No conflicts to disclose. Any relationship with industry is declared. References [1] M. Francesco, The evolution of MitraClip in the repair of mitral regurgitation, Eur Heart J 21 (36) (2015) 1201–1202. [2] P. Boekstegers, J. Hausleiter, S. Baldus, R.S. von Bardeleben, H. Beucher, C. Butter, et al., Percutaneous interventional mitral regurgitation treatment using the Mitra-Clip system, Clin. Res. Cardiol. Off. J. Ger. Card. Soc. 103 (2014) 85–96. [3] K. Boerlage-vanDijk, E.M.A. Wiegerinck, M. Araki, P.G. Meregalli, N.R. Bindraban, K.T. Koch, et al., Predictors of outcome in patients undergoing MitraClip implantation: an aid to improve patient selection, Int J Cardiol 189 (2015) 238–243. [4] P. Gripari, F. Maffessanti, G. Tamborini, M. Muratori, L. Fusini, S. Ghulam Ali, et al., Patients selection for MitraClip: time to move to transthoracic echocardiographic screening? Int J Cardiol 176 (2014) 491–494. [5] F. Kreidel, C. Frerker, M. Schlüter, H. Alessandrini, T. Thielsen, S. Geidel, et al., Repeat MitraClip therapy for significant recurrent mitral regurgitation in high surgical risk patients: impact of loss of leaflet insertion, JACC Cardiovasc Interv 8 (2015) 1480–1489.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Mitral annuloplasty ring and two MitraClip® devices: Quintuple diastolic filling orifice Fernando Carrasco-Chinchilla, Isabel Rodríguez-Bailón, Juan Alonso Briales ⁎, Antonio Domínguez-Franco, Antonio Muñoz-García, Eduardo deTeresa-Galván, José María Hernández-García Virgen de la Victoria Hospital, Spain
a r t i c l e
i n f o
Article history: Received 5 October 2015 Accepted 13 October 2015 Available online 23 October 2015 Keywords: Mitral regurgitation Mitral annuloplasty Mitraclip
The MitraClip® system allows offering of treatment to patients with mitral regurgitation and high surgical risk [1]. The growing experience of centers can overcome the initial anatomical restrictions evaluated by echocardiography and treat increasingly complex cases [2,3]. A 54 years old male patient affected by three vessel ischemic heart disease with mild systolic dysfunction and secondary moderate mitral regurgitation was treated by cardiac surgery (coronary artery bypass grafting with concomitant reductive annuloplasty ring implantation). After six years, patient presented heart failure and had developed severe ventricular dysfunction and functional severe mitral regurgitation. The
Fig. 1. A: three-dimensional echocardiography showing annuloplasty ring and MitraClip® devices (*,*). Periannular filling holes are noted. B: ColorDoppler with quintuple-orifice of diastolic filling. C: Systolic image showing mild to moderate mitral regurgitation. ⁎ Corresponding author at: Virgen de la Victoria Hospital, Campus Universitario Teatinos s/n, Málaga, Spain. E-mail address: [email protected] (J.A. Briales).
http://dx.doi.org/10.1016/j.ijcard.2015.10.114 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Correspondence
triple coronary bypass was patent. After being discussed by the heart team, we decided to try to repair the valve percutaneously with the MitraClip® device. The annuloplasty ring can makethe device implantation difficult: the antero-posterior diameter of the ring is smaller than that of the opened clip, so it was necessary to introduce the device closed through the ring. On the other hand, poor echocardiographic image quality can be obtained during the procedure due to acoustic shadows produced by the ring (mainly for the grasping). Implantation of a single MitraClip® device was finally performed with good clinical and echocardiographic results (moderate regurgitation and no stenosis). But nevertheless, one year later the patient again presented heart failure refractory to medical treatment and severe mitral regurgitation. Exhaustive evaluation by transthoracic and transesophageal echocardiographies [4] can identify the mechanism of mitral regurgitation and assess whether the problem can be solved with a new device [5]. Echocardiogram shows the MitraClip® was properly attached to the leaflets, and no perforation or other damage leaflets were noted, however a new regurgitation jet had appeared near the device, due to restrictive movement of the posterior leaflet.After debating with the heart team, a new device implantation was indicated. Mitral stenosis could be the main handicap for a new MitraClip® implantation. The second device was successfully implanted close to the first MitraClip®, achieving significant reduction of mitral regurgitation. In the three-dimensional echocardiographic image quintuple diastolic filling orifice was noted (Fig. 1A, B). Two orifices were located near the MitraClip® devices and inside the annuloplasty ring (red arrows). Three additional orifices (green arrows) were situated outside the ring, with important contribution to the left ventricular filling and
183
without systolic flow (no periprosthetic regurgitation (Fig. 1C, video)). Periannular holes with isolated diastolic flow had been noted previously when we performed the first MitraClip® implantation. This is the first reported case of successful implantation of second MitraClip® in patient with previous MitraClip® and mitral annuloplasty ring. Existence of peri-annular filling holes probably contributes to the absence of stenosis. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.10.114. Conflict of interest No conflicts to disclose. Any relationship with industry is declared. References [1] M. Francesco, The evolution of MitraClip in the repair of mitral regurgitation, Eur Heart J 21 (36) (2015) 1201–1202. [2] P. Boekstegers, J. Hausleiter, S. Baldus, R.S. von Bardeleben, H. Beucher, C. Butter, et al., Percutaneous interventional mitral regurgitation treatment using the Mitra-Clip system, Clin. Res. Cardiol. Off. J. Ger. Card. Soc. 103 (2014) 85–96. [3] K. Boerlage-vanDijk, E.M.A. Wiegerinck, M. Araki, P.G. Meregalli, N.R. Bindraban, K.T. Koch, et al., Predictors of outcome in patients undergoing MitraClip implantation: an aid to improve patient selection, Int J Cardiol 189 (2015) 238–243. [4] P. Gripari, F. Maffessanti, G. Tamborini, M. Muratori, L. Fusini, S. Ghulam Ali, et al., Patients selection for MitraClip: time to move to transthoracic echocardiographic screening? Int J Cardiol 176 (2014) 491–494. [5] F. Kreidel, C. Frerker, M. Schlüter, H. Alessandrini, T. Thielsen, S. Geidel, et al., Repeat MitraClip therapy for significant recurrent mitral regurgitation in high surgical risk patients: impact of loss of leaflet insertion, JACC Cardiovasc Interv 8 (2015) 1480–1489.