- Email: [email protected]
Multiple Interventional Procedures as an Alternative to Cardiac Transplantation
JACC: CASE REPORTS
VOL. 1, NO. 1, 2019
ª 2019 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT HEART CARE TEAM/MULTIDISCIPLINARY TEAM LIVE
Multiple Interventional Procedures as an Alternative to Cardiac Transplantation Katrien Blanchart, MD,a Eric Saloux, MD,a Remi Sabatier, MD, PHD,a Vincent Roule, MD,a,b Farzin Beygui, MD, PHDa,b,c
ABSTRACT Heart failure (HF) is an increasing pandemic affecting more than 26 million people worldwide. Despite growing therapeutic options, the outlook of patients with HF remains particularly poor with high mortality and rehospitalization rates. When HF remains uncontrolled despite optimal medical therapy, mechanical circulatory devices or heart transplantation must be considered. Unfortunately, these therapeutic options are limited. This case explains how consecutive minimally invasive treatment allowed stabilization of end-stage HF thereby avoiding heart transplantation or mechanical assist devices. (Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep 2019;1:1–4) © 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A
64-year-old patient with a medical history of
On admission, he presented with cardiogenic shock
hypertension presented with dyspnea to the
requiring dobutamine support. Echocardiography
emergency department of a secondary care
showed severe left ventricular (LV) systolic dysfunc-
hospital. The electrocardiogram showed left bundle
tion (LV ejection fraction [LVEF], 35%) with extensive
branch block (LBBB) with significant ST-segment
akinesis of the anterior wall. Coronary angiography
elevation in the anterior leads. The patient was trans-
showed proximal left anterior descending artery oc-
ferred to our hospital (Caen University Hospital) for
clusion and stenosis of the proximal circumflex artery
primary percutaneous coronary intervention (PCI).
(Video 1). Question 1: What would be the preferred PCI
LEARNING OBJECTIVES To understand the role of a multidisciplinary approach in the management of patients with advanced heart failure. To identify and correct multiple causes leading to end-stage heart failure. To understand that a stepwise optimization strategy in severe heart failure, including medical therapy optimization and adequately staged interventional procedures, may improve outcome while avoiding transplantation or mechanical assist destination therapy.
strategy for multivessel coronary artery disease in the setting of acute myocardial infarction complicated by cardiogenic shock? Answer 1: The most recent guidelines (1) recommend primary PCI only of the culprit lesion in this setting (Class III, Level of Evidence: B) on the basis of the results of the CULPRIT-SHOCK trial (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) (2), showing that multivessel primary PCI is associated with an increased risk of the composite outcome of all-cause mortality or severe renal failure, both at 30 days and 1 year, when compared with culprit lesion–only primary PCI.
From the aDepartment of Cardiology, Caen University Hospital, Caen, France; bResearch Group 4650, Normandy University, Caen, France; and the cACTION Study Group, Pitié-Salpêtrière University Hospital, Paris, France. Dr. Beygui has received institutional research grants from Medtronic, Biosensor, Boston Scientific, Acist, and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 4, 2019; revised manuscript received May 2, 2019, accepted May 9, 2019.
ISSN 2666-0849
https://doi.org/10.1016/j.jaccas.2019.05.020
2
Blanchart et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:1–4
Staged Procedures to Avoid Transplantation
score determined by computed tomography favors
F I G U R E 1 Final Fluoroscopy
significant AS (3). Question 3: What is the best treatment for AS in patients with severe LV dysfunction? Answer 3: Although patients without flow reserve have a higher operative mortality, both surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) have been shown to improve LVEF and clinical status. The ability to identify patients with severe AS in this subgroup by computed tomography calcium scoring and the availability of TAVR have lowered the threshold to intervene (3). The choice for intervention must be based on careful individual evaluation of technical suitability and the risks and benefits of each option. SAVR is recommended in patients at low surgical risk. TAVR is recommended in patients at high surgical risk, as assessed by the heart team.
Left anterior descending artery and circumflex artery stents, transcatheter aortic valve replacement (TAVR), and MitraClip (Abbott, Lake Bluff, Illinois) use. Also see Videos 1, 2, 3, 4, 5, 6, and 7. CRT-D ¼ cardiac resynchronization therapy with an implantable defibrillator.
Because of high surgical risk (EuroSCORE II >17%), our patient was selected for TAVR. The procedure was successfully performed in July 2016 with a 26-mm Sapien 3 valve (Edwards Lifesciences, Irvine,
However, when our patient was admitted, guidelines recommended multivessel PCI in this setting, so the patient underwent multivessel primary PCI with drug-eluting stents implanted in the left anterior
California). Question 4: What is the expected evolution of LVEF after TAVR? Answer 4: It depends on its cause. In patients with low-flow, low-gradient AS and reduced LVEF
descending and circumflex arteries (Video 2). The patient recovered and was discharged to a
whose depressed LVEF is predominantly caused
cardiac rehabilitation center. He was readmitted
by excessive afterload, LVEF usually improves after
2
shock
intervention. LVEF improvement is uncertain if
requiring inotropic support. Transthoracic echocar-
the primary cause is myocardial infarction or
diography
cardiomyopathy.
weeks
later
for
during
recurrent dobutamine
cardiogenic infusion
showed
severely decreased LV function (LVEF, 21%), moder-
In
October
2016,
3
months
after
successful
ate mitral regurgitation (MR), and significant low-
TAVR, the patient still had persistent dyspnea
gradient aortic stenosis (AS) with a mean gradient of
and LV dysfunction (LVEF, 34%) with moderate MR.
21 mm Hg and an aortic valve area of 0.81 cm 2. BSA
The electrocardiogram showed sinus rhythm with
at the time of diagnosis of severe AS was 2.17 (height
LBBB (QRS complex duration, 130 ms) on medical
182 cm, weight 92 kg) and so AVA indexed 0.37 cm2
therapy, including ramipril 10 mg, bisoprolol 5 mg,
(0.81/2.17).
spironolactone 25 mg, furosemide 125 mg, and ivab-
Question 2: Which approach should be used for the echocardiographic diagnosis of AS with low cardiac output?
radine 10 mg daily. Question 5: How would you optimize the management of the patient?
Answer 2: In cardiogenic shock with low cardiac
Answer 5: In case of persistent symptoms of heart
output, the transvalvular aortic valve gradients are
failure (HF) in patients with sinus rhythm, QRS
significantly reduced, explaining why the diagnosis
complex duration of 130 to 149 ms, LBBB configura-
was missed on the initial echocardiogram. In low-
tion, and LVEF £35%, cardiac resynchronization
flow, low-gradient AS with reduced LVEF, low-dose
therapy with an implantable defibrillator (CRT-D) is
dobutamine echocardiography is recommended to
recommended to improve symptoms and reduce
distinguish truly severe AS from pseudo-severe AS,
mortality (4).
defined by an increase of the aortic valve area
According to the PARADIGM trial (Angiotensin–
>1.0 cm 2 with flow normalization. The presence of a
Neprilysin Inhibition versus Enalapril in Heart Fail-
flow reserve is associated with improved outcome.
ure), a combination of sacubitril and valsartan is
In the absence of flow reserve, a high calcium
recommended as a replacement for angiotensin-
Blanchart et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:1–4
Staged Procedures to Avoid Transplantation
converting enzyme inhibitor therapy to reduce the
Answer 7: MR may be overestimated in patients
risk of HF hospitalization and death further in
with severe AS. Treating the AS first and decreasing
ambulatory patients with reduced LVEF who remain
LV pressure can reduce MR (6). Pre-existing MR in
symptomatic despite optimal treatment with an
patients presenting for TAVR has been related to
angiotensin-converting enzyme inhibitor, a beta-
greater need for hemodynamic support, longer
blocker, and a mineralocorticoid receptor antagonist
hospital stays, and higher in-hospital and 6-month
(4).
mortality (6). Therefore, treatment of MR after TAVR
The patient underwent CRT-D implantation, and ramipril was replaced by the sacubitril-valsartan
should be considered. Because a decrease in MR severity after TAVR is
remained
possible, staging the 2 interventions starting with
severely symptomatic (New York Heart Association
TAVR seems more reasonable. Recent reviews show
functional class III dyspnea), with high B-type natri-
that a staged approach, beginning with TAVR
uretic peptide levels (1,400 pg/ml) and low peak ox-
and followed by MitraClip placement, is the most
ygen
common strategy (7).
combination.
In
November
consumption
(14
2016,
he
ml/kg/min).
Control
echocardiography (Videos 3, 4, 5, and 6) showed se-
Recent randomized studies (8,9) comparing medi-
vere secondary MR (regurgitant orifice area, 0.3 cm 2)
cal treatment versus MitraClip use in secondary MR
and low LVEF (34%) with moderate remodeling (LV
with HF and decreased LVEF showed conflicting
end-diastolic volume, 75 ml/m 2).
results. Unlike the COAPT (Cardiovascular Outcomes
Question 6: At this time, should the patient be
Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral
considered for cardiac transplantation? and
Regurgitation) trial showing a significant benefit
echocardiographic
in terms of mortality, the MITRA-FR (Multicentre
improvement on optimized treatment, mechanical
Randomized Study of Percutaneous Mitral Valve
circulatory support as destination therapy or heart
Repair MitraClip Device in Patients With Severe Sec-
transplantation should be considered in these
ondary Mitral Regurgitation) trial, which included
patients (5).
patients with less severe MR and more severe
Answer the
6:
absence
Because of
of
clinical
poor and
prognosis
After evaluation by the heart team, the patient was considered a candidate for heart transplantation.
remodeling, failed to show a benefit. Our
patient
was
an
adequate
candidate
for
However, because of his relative stability and the
MitraClip after TAVR because despite severe HF
known shortage of donor hearts, his expected waiting
and
time was long. A percutaneous intervention on
ventricular remodeling with significant MR. His long-
the mitral valve to reduce MR was decided after
term outcome was satisfactory, and heart trans-
evaluation of its suitability by transesophageal
plantation or ventricular assist device implantation
echocardiography. A successful MitraClip (Abbott,
was avoided.
low
LVEF,
he
had
relatively
moderate
Lake Bluff, Illinois) procedure with 1 clip was per-
This case demonstrates that staged interventional
formed in December 2016 (Figure 1). In June 2018, the
procedures may lead to stabilization and regression
patient had no symptoms, and B-type natriuretic
of HF with multiple underlying mechanisms. A
peptide levels were decreased to 348 pg/ml. Echo-
multidisciplinary approach with the heart team is
cardiography (Video 7) showed mild residual MR,
essential in the management of advanced complex
a mean transmitral gradient of 4 mm Hg, and a
HF.
significantly increased LVEF (48%). Question 7: Could the favorable effect of the
ADDRESS
FOR
CORRESPONDENCE:
Dr.
Katrien
MitraClip have been predicted in this patient? In our
Blanchart, Department of Cardiology, Caen University
case, what should have been the optimal timing for
Hospital, Avenue Côte de Nacre, 14033 Caen, France.
MR treatment?
E-mail: [email protected].
REFERENCES 1. Neumann F-J, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS guidelines on
3. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of
the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiol-
myocardial revascularization. 2019;40:87–165.
J
valvular heart disease. Eur Heart J 2017;38: 2739–91.
2. Thiele H, Akin I, Sandri M, et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med 2018;379:1699–710.
4. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for
ogy (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129–200.
Eur
Heart
5. Crespo-Leiro MG, Metra M, Lund LH, et al. Advanced heart failure: a position statement of the
3
4
Blanchart et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:1–4
Staged Procedures to Avoid Transplantation
Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018;20:1505–35.
aortic and mitral valve interventions. Catheter Cardiovasc Interv 2018;91:124–34.
6. Cortés C, Amat-Santos IJ, Nombela-Franco L, et al. Mitral regurgitation after transcatheter aortic valve replacement: prognosis, imaging predictors, and potential management. J Am Coll
8. Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med 2018;379:2307–18.
Cardiol Intv 2016;9:1603–14.
9. Obadia J-F, Messika-Zeitoun D, Leurent G, et al. Percutaneous repair or medical treatment for
7. Ando T, Takagi H, Briasoulis A, et al. A systematic review of reported cases of combined transcatheter
secondary mitral regurgitation. N Engl J Med 2018;379:2297–306.
KEY WORDS cardiac transplantation, heart failure, heart team, MitraClip, percutaneous mitral valve repair, transcatheter aortic valve replacement
AP PE NDIX For supplemental videos, please see the online version of this paper.
VOL. 1, NO. 1, 2019
ª 2019 THE AUTHORS. PUBLISHED BY ELSEVIER ON BEHALF OF THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION. THIS IS AN OPEN ACCESS ARTICLE UNDER THE CC BY-NC-ND LICENSE (http://creativecommons.org/licenses/by-nc-nd/4.0/).
CASE REPORT HEART CARE TEAM/MULTIDISCIPLINARY TEAM LIVE
Multiple Interventional Procedures as an Alternative to Cardiac Transplantation Katrien Blanchart, MD,a Eric Saloux, MD,a Remi Sabatier, MD, PHD,a Vincent Roule, MD,a,b Farzin Beygui, MD, PHDa,b,c
ABSTRACT Heart failure (HF) is an increasing pandemic affecting more than 26 million people worldwide. Despite growing therapeutic options, the outlook of patients with HF remains particularly poor with high mortality and rehospitalization rates. When HF remains uncontrolled despite optimal medical therapy, mechanical circulatory devices or heart transplantation must be considered. Unfortunately, these therapeutic options are limited. This case explains how consecutive minimally invasive treatment allowed stabilization of end-stage HF thereby avoiding heart transplantation or mechanical assist devices. (Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep 2019;1:1–4) © 2019 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
A
64-year-old patient with a medical history of
On admission, he presented with cardiogenic shock
hypertension presented with dyspnea to the
requiring dobutamine support. Echocardiography
emergency department of a secondary care
showed severe left ventricular (LV) systolic dysfunc-
hospital. The electrocardiogram showed left bundle
tion (LV ejection fraction [LVEF], 35%) with extensive
branch block (LBBB) with significant ST-segment
akinesis of the anterior wall. Coronary angiography
elevation in the anterior leads. The patient was trans-
showed proximal left anterior descending artery oc-
ferred to our hospital (Caen University Hospital) for
clusion and stenosis of the proximal circumflex artery
primary percutaneous coronary intervention (PCI).
(Video 1). Question 1: What would be the preferred PCI
LEARNING OBJECTIVES To understand the role of a multidisciplinary approach in the management of patients with advanced heart failure. To identify and correct multiple causes leading to end-stage heart failure. To understand that a stepwise optimization strategy in severe heart failure, including medical therapy optimization and adequately staged interventional procedures, may improve outcome while avoiding transplantation or mechanical assist destination therapy.
strategy for multivessel coronary artery disease in the setting of acute myocardial infarction complicated by cardiogenic shock? Answer 1: The most recent guidelines (1) recommend primary PCI only of the culprit lesion in this setting (Class III, Level of Evidence: B) on the basis of the results of the CULPRIT-SHOCK trial (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) (2), showing that multivessel primary PCI is associated with an increased risk of the composite outcome of all-cause mortality or severe renal failure, both at 30 days and 1 year, when compared with culprit lesion–only primary PCI.
From the aDepartment of Cardiology, Caen University Hospital, Caen, France; bResearch Group 4650, Normandy University, Caen, France; and the cACTION Study Group, Pitié-Salpêtrière University Hospital, Paris, France. Dr. Beygui has received institutional research grants from Medtronic, Biosensor, Boston Scientific, Acist, and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Manuscript received April 4, 2019; revised manuscript received May 2, 2019, accepted May 9, 2019.
ISSN 2666-0849
https://doi.org/10.1016/j.jaccas.2019.05.020
2
Blanchart et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:1–4
Staged Procedures to Avoid Transplantation
score determined by computed tomography favors
F I G U R E 1 Final Fluoroscopy
significant AS (3). Question 3: What is the best treatment for AS in patients with severe LV dysfunction? Answer 3: Although patients without flow reserve have a higher operative mortality, both surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) have been shown to improve LVEF and clinical status. The ability to identify patients with severe AS in this subgroup by computed tomography calcium scoring and the availability of TAVR have lowered the threshold to intervene (3). The choice for intervention must be based on careful individual evaluation of technical suitability and the risks and benefits of each option. SAVR is recommended in patients at low surgical risk. TAVR is recommended in patients at high surgical risk, as assessed by the heart team.
Left anterior descending artery and circumflex artery stents, transcatheter aortic valve replacement (TAVR), and MitraClip (Abbott, Lake Bluff, Illinois) use. Also see Videos 1, 2, 3, 4, 5, 6, and 7. CRT-D ¼ cardiac resynchronization therapy with an implantable defibrillator.
Because of high surgical risk (EuroSCORE II >17%), our patient was selected for TAVR. The procedure was successfully performed in July 2016 with a 26-mm Sapien 3 valve (Edwards Lifesciences, Irvine,
However, when our patient was admitted, guidelines recommended multivessel PCI in this setting, so the patient underwent multivessel primary PCI with drug-eluting stents implanted in the left anterior
California). Question 4: What is the expected evolution of LVEF after TAVR? Answer 4: It depends on its cause. In patients with low-flow, low-gradient AS and reduced LVEF
descending and circumflex arteries (Video 2). The patient recovered and was discharged to a
whose depressed LVEF is predominantly caused
cardiac rehabilitation center. He was readmitted
by excessive afterload, LVEF usually improves after
2
shock
intervention. LVEF improvement is uncertain if
requiring inotropic support. Transthoracic echocar-
the primary cause is myocardial infarction or
diography
cardiomyopathy.
weeks
later
for
during
recurrent dobutamine
cardiogenic infusion
showed
severely decreased LV function (LVEF, 21%), moder-
In
October
2016,
3
months
after
successful
ate mitral regurgitation (MR), and significant low-
TAVR, the patient still had persistent dyspnea
gradient aortic stenosis (AS) with a mean gradient of
and LV dysfunction (LVEF, 34%) with moderate MR.
21 mm Hg and an aortic valve area of 0.81 cm 2. BSA
The electrocardiogram showed sinus rhythm with
at the time of diagnosis of severe AS was 2.17 (height
LBBB (QRS complex duration, 130 ms) on medical
182 cm, weight 92 kg) and so AVA indexed 0.37 cm2
therapy, including ramipril 10 mg, bisoprolol 5 mg,
(0.81/2.17).
spironolactone 25 mg, furosemide 125 mg, and ivab-
Question 2: Which approach should be used for the echocardiographic diagnosis of AS with low cardiac output?
radine 10 mg daily. Question 5: How would you optimize the management of the patient?
Answer 2: In cardiogenic shock with low cardiac
Answer 5: In case of persistent symptoms of heart
output, the transvalvular aortic valve gradients are
failure (HF) in patients with sinus rhythm, QRS
significantly reduced, explaining why the diagnosis
complex duration of 130 to 149 ms, LBBB configura-
was missed on the initial echocardiogram. In low-
tion, and LVEF £35%, cardiac resynchronization
flow, low-gradient AS with reduced LVEF, low-dose
therapy with an implantable defibrillator (CRT-D) is
dobutamine echocardiography is recommended to
recommended to improve symptoms and reduce
distinguish truly severe AS from pseudo-severe AS,
mortality (4).
defined by an increase of the aortic valve area
According to the PARADIGM trial (Angiotensin–
>1.0 cm 2 with flow normalization. The presence of a
Neprilysin Inhibition versus Enalapril in Heart Fail-
flow reserve is associated with improved outcome.
ure), a combination of sacubitril and valsartan is
In the absence of flow reserve, a high calcium
recommended as a replacement for angiotensin-
Blanchart et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:1–4
Staged Procedures to Avoid Transplantation
converting enzyme inhibitor therapy to reduce the
Answer 7: MR may be overestimated in patients
risk of HF hospitalization and death further in
with severe AS. Treating the AS first and decreasing
ambulatory patients with reduced LVEF who remain
LV pressure can reduce MR (6). Pre-existing MR in
symptomatic despite optimal treatment with an
patients presenting for TAVR has been related to
angiotensin-converting enzyme inhibitor, a beta-
greater need for hemodynamic support, longer
blocker, and a mineralocorticoid receptor antagonist
hospital stays, and higher in-hospital and 6-month
(4).
mortality (6). Therefore, treatment of MR after TAVR
The patient underwent CRT-D implantation, and ramipril was replaced by the sacubitril-valsartan
should be considered. Because a decrease in MR severity after TAVR is
remained
possible, staging the 2 interventions starting with
severely symptomatic (New York Heart Association
TAVR seems more reasonable. Recent reviews show
functional class III dyspnea), with high B-type natri-
that a staged approach, beginning with TAVR
uretic peptide levels (1,400 pg/ml) and low peak ox-
and followed by MitraClip placement, is the most
ygen
common strategy (7).
combination.
In
November
consumption
(14
2016,
he
ml/kg/min).
Control
echocardiography (Videos 3, 4, 5, and 6) showed se-
Recent randomized studies (8,9) comparing medi-
vere secondary MR (regurgitant orifice area, 0.3 cm 2)
cal treatment versus MitraClip use in secondary MR
and low LVEF (34%) with moderate remodeling (LV
with HF and decreased LVEF showed conflicting
end-diastolic volume, 75 ml/m 2).
results. Unlike the COAPT (Cardiovascular Outcomes
Question 6: At this time, should the patient be
Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral
considered for cardiac transplantation? and
Regurgitation) trial showing a significant benefit
echocardiographic
in terms of mortality, the MITRA-FR (Multicentre
improvement on optimized treatment, mechanical
Randomized Study of Percutaneous Mitral Valve
circulatory support as destination therapy or heart
Repair MitraClip Device in Patients With Severe Sec-
transplantation should be considered in these
ondary Mitral Regurgitation) trial, which included
patients (5).
patients with less severe MR and more severe
Answer the
6:
absence
Because of
of
clinical
poor and
prognosis
After evaluation by the heart team, the patient was considered a candidate for heart transplantation.
remodeling, failed to show a benefit. Our
patient
was
an
adequate
candidate
for
However, because of his relative stability and the
MitraClip after TAVR because despite severe HF
known shortage of donor hearts, his expected waiting
and
time was long. A percutaneous intervention on
ventricular remodeling with significant MR. His long-
the mitral valve to reduce MR was decided after
term outcome was satisfactory, and heart trans-
evaluation of its suitability by transesophageal
plantation or ventricular assist device implantation
echocardiography. A successful MitraClip (Abbott,
was avoided.
low
LVEF,
he
had
relatively
moderate
Lake Bluff, Illinois) procedure with 1 clip was per-
This case demonstrates that staged interventional
formed in December 2016 (Figure 1). In June 2018, the
procedures may lead to stabilization and regression
patient had no symptoms, and B-type natriuretic
of HF with multiple underlying mechanisms. A
peptide levels were decreased to 348 pg/ml. Echo-
multidisciplinary approach with the heart team is
cardiography (Video 7) showed mild residual MR,
essential in the management of advanced complex
a mean transmitral gradient of 4 mm Hg, and a
HF.
significantly increased LVEF (48%). Question 7: Could the favorable effect of the
ADDRESS
FOR
CORRESPONDENCE:
Dr.
Katrien
MitraClip have been predicted in this patient? In our
Blanchart, Department of Cardiology, Caen University
case, what should have been the optimal timing for
Hospital, Avenue Côte de Nacre, 14033 Caen, France.
MR treatment?
E-mail: [email protected].
REFERENCES 1. Neumann F-J, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS guidelines on
3. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of
the Diagnosis and Treatment of Acute and Chronic Heart Failure of the European Society of Cardiol-
myocardial revascularization. 2019;40:87–165.
J
valvular heart disease. Eur Heart J 2017;38: 2739–91.
2. Thiele H, Akin I, Sandri M, et al. One-year outcomes after PCI strategies in cardiogenic shock. N Engl J Med 2018;379:1699–710.
4. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for
ogy (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37:2129–200.
Eur
Heart
5. Crespo-Leiro MG, Metra M, Lund LH, et al. Advanced heart failure: a position statement of the
3
4
Blanchart et al.
JACC: CASE REPORTS, VOL. 1, NO. 1, 2019 JUNE 2019:1–4
Staged Procedures to Avoid Transplantation
Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018;20:1505–35.
aortic and mitral valve interventions. Catheter Cardiovasc Interv 2018;91:124–34.
6. Cortés C, Amat-Santos IJ, Nombela-Franco L, et al. Mitral regurgitation after transcatheter aortic valve replacement: prognosis, imaging predictors, and potential management. J Am Coll
8. Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med 2018;379:2307–18.
Cardiol Intv 2016;9:1603–14.
9. Obadia J-F, Messika-Zeitoun D, Leurent G, et al. Percutaneous repair or medical treatment for
7. Ando T, Takagi H, Briasoulis A, et al. A systematic review of reported cases of combined transcatheter
secondary mitral regurgitation. N Engl J Med 2018;379:2297–306.
KEY WORDS cardiac transplantation, heart failure, heart team, MitraClip, percutaneous mitral valve repair, transcatheter aortic valve replacement
AP PE NDIX For supplemental videos, please see the online version of this paper.