Transcript Percutaneous Mitral Valve Repair With The MitraClip Device

CASO CLINICO:
PERCUTANEUS MITRAL VALVE REPAIR
Dr. Giuseppe Grasssi
Direttore UO Cardiologia
VENEZIA
history and physical exam
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67 yrs old female
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no known cardiovascular risk factors, no past medical
history
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ER admission after 2 hours from symptoms onset
(chest pain, first episode)
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BP135/80, HR 85 bpm, peripheral blood oxygen
saturation 99% (room air), physical exam unremarkable
except for mild systolic murmur at the apex, no signs of
pulmonary congestion
ekg at admission
posterior STEMI
first invasive pressure tracing:
hypotension
emergent coronary
angiography
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despite good angiographic result (TIMI 3 flow, no
dissection, no residual thormbus, no apparent thrombus
migration, only loss of tiny posterobasal branch)
hyoptension & EKG sings of posterior ischemia persist
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inotropes started (dopamine 8 mcg/Kg/min)
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patient gets restless
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rapid onset of pulmonary oedema
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need for emergent airway intubation and IABP
counterpulsation
massive mitral regurgitation, possibly due to
papillary muscle rupture
CALL THE HEART SURGEONS FOR EMERGERGENT
MITRAL VALVE REPAIR!
tee revealed papillary muscle flail
heart team discussion
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indication for MV surgery:
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no doubt
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surgical risk: very high, Euroscore 24% (female, 67 yrs,
recent myocardial infarction, critical conditions
[mechanical ventilation, IABP, inotrpes], emergent
intervention, open heart surgery) + papillary muscle
rupture
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but...
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OR not available because of other ongoing open heart
interevntion
what next?
heart team discussion
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try to stabilize the patient with medical therapy and
IABP
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wait for OR availability
persistent, profound hypotension
new heart team discussion
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medical therapy and IABP support are insufficient
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a “bridge solution” should be found: percutaneus VAD
or percutaneous mitral valve repair
new heart team discussion:
“bridge solutions”
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Impella/Tandem Heart: not available at our Institution
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ECMO: not possible because perfusionists busy with
the ongoing intervention
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MitraClip Intervention: device available but serious
concerns about anatomical feasibility, procedural time,
haemodynamic stability
EMERGENT mitraclip
intervention
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Anatomical feasibility ? papillary muscle flail with large
flail gap and width. Coaptation length possibly not a
problem.
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Procedural time? not predictable, but probably long;
major concern given patients’ heamodynamics
tee
tee
emergent mitraclip procedure
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despite high risk of procedural failure and
intraprocedural death, the decision was taken to go on
with the MItraClip intervention
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no problems found during initial procedural steps
including vascular access site puncture, trans-septal
puncture, guiding catheter positioning, and MitraClip
device steering towards the mitral leaflets.
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Patient still severly hypotensive but somehow stable
emergent mitraclip procedure
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main regurgitant jet localized between A1-P1 and A2P2, smaller jet originated more medially
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leaflet grasping in the zone of the major regurgitant jet
was impossible due to the large flail gap
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a more medial grasp was successfully attempted in
order to narrow the flail gap
first clip positioning
emergent mitraclip procedure
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the first clip reduced the flail gap enough to narrow the
leaflets so that they could be grasped by a second clip
second clip
emergent mitraclip procedure
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The second clip reduced significantly the MR, which
nevertheless remained at least moderate
emergent mitraclip procedure
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2 clip positioned, good
TEE and angiographic
result
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rapid haemodynamic
improvement
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procedural time: about 2
hours (skin to skin)
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transferred to ICU
follow up
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weaned from mechanical ventilation after 3 days
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weaned from IABP after 5 days
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echo: normal LV dimensions, normal EF, moderate
residual MR, no evidence of (partial) clip detachment
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development of allergic skin reaction to clopidogrel
requiring treatment with steroids and switch to
prasugrel
follow up
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after 10 days transferred to normal
ward
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during following days episodes of
arterial hypotension
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evidence of progressive MR
worsening with preserved ventricular
function
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MVR planned and carried on after 5
weeks from admission (bioprosthesis)
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dischareged 6 days after MVR
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asymptomatic at follow up, preserved
EF, normal bioprosthesis function
thank you!