Repeated MitraClip procedure in patients with recurrent MR after a successful first procedure: Limitations and outcome

Objectives

The present study aimed to evaluate the outcome and potential limitations of a repeated MitraClip procedure (ReClip).

Background

The MitraClip procedure has emerged as a treatment option in high surgical risk patients suffering from severe mitral regurgitation (MR). However, despite successful initial repair a significant number of patients develops severe recurrent MR.

Methods

Patients undergoing a ReClip procedure in our institution were retrospectively identified. Baseline data and the procedural outcome were assessed to identify potential limitations of such procedures.

Results

Fifteen out of 234 patients undergoing a mitral‐valve repair with the MitraClip device (Abbott Vascular) underwent a ReClip due to recurrent MR. In 11 patients, a MR reduction of at least one degree without causing mitral valve stenosis (trans‐mitral mean gradient ≥5 mmHg) was achieved by performing a ReClip. After 1 year, two patients developed severe recurrent MR again. Pulmonary artery pressures significantly decreased after the procedure in individuals with successful repair (MR reduction of at least one degree and mitral valve mean gradient <5 mmHg).

Conclusion

A ReClip procedure may be feasible in patients with recurrent MR but the risk benefit ratio should be carefully balanced against other treatment options.     

Predictors for long‐term survival after transcatheter edge‐to‐edge mitral valve repair

Objectives

To determine predictors for long‐term outcome in high‐risk patients undergoing transcatheter edge‐to‐edge mitral valve repair (TMVR) for severe mitral regurgitation (MR).

Background

There is no data on predictors of long‐term outcome in high‐risk real‐world patients.

Methods

From August 2009 to April 2011, 126 high‐risk patients deemed inoperable were treated with TMVR in two high‐volume university centers.

Results

MR could be successfully reduced to grade ≤2 in 92.1% of patients (116/126 patients). Long‐term clinical follow‐up up to 5 years (95.2% follow‐up rate) revealed a mortality rate of 35.7% (45/126 patients). Repeat mitral valve treatment (surgery or intervention) was needed in 19 patients (15.1%). Long‐term clinical improvement was demonstrated with 69% of patients being in NYHA class ≤II. In a multivariable Cox regression analysis, the post‐procedural grade of MR (hazard ratio [HR] 1.55 per grade, P = 0.035), the left ventricular ejection fraction (HR 0.58 for difference between 75th and 25th percentile, P = 0.031) and the glomerular filtration rate (HR 0.33 for 75th vs 25th percentile, P < 0.001) were independent predictors for long‐term mortality. Patients with primary MR and a post‐procedural MR grade ≤1 had the most favorable long‐term outcome.

Conclusions

This study determines predictors of long‐term clinical outcome after TMVR and demonstrates that the grade of residual MR determines long‐term survival. Our data suggest that it might be of benefit reducing residual MR to the lowest possible MR grade using TMVR—especially in selected high‐risk patients with primary MR who are not considered as candidates for surgical MVR.

     

Echocardiographic evaluation of mitral valve repair by modified "edge to edge" technique

The "edge to edge" or "double-orifice" technique is an alternative surgical option of mitral valve repair to treat mitral regurgitation. Echocardiography is very useful to evaluate the postoperative valve function, but since this technique is not frequently used, there is little experience about its echocardiographic features, which are different from those of the classic mitral valve repair. In this report, we present a patient who underwent this repair with a modified approach called "triple-orifice technique" and was evaluated by transthoracic and transesophageal echocardiography.     

The valve‐in‐valve technique: Transcatheter treatment of aortic bioprothesis malposition

Percutaneous aortic valve replacement is an emerging alternative to palliative medical therapy for nonsurgical patients with severe aortic valve stenosis. The impossibility of repositioning of the current transcatheter prosthesis in case of suboptimal placement is the main limit of these devices. Here, we report on a case of an 84‐year‐old woman successfully treated with implantation of two 18‐Fr CoreValve® prosthesis (CoreValve®, Irvine, California), because of the suboptimal deployment of the first one, analyzing the procedural technique and the immediate and short‐term clinical and hemodynamic results. © 2009 Wiley‐Liss, Inc.     

“缘对缘”联合人工瓣环修复术治疗二尖瓣关闭不全42例分析

【】 目的 探讨“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全的手术效果。方法 回顾性分析2004年1月至2008年12月对42例非风湿性二尖瓣关闭不全患者行“缘对缘”联合人工瓣环修复二尖瓣成形术的临床资料,男25例,女17例;年龄12～69岁(36.42±14.28岁),其中先天性二尖瓣病变12例,瓣膜退行性病变20例,缺血性二尖瓣关闭不全7例,感染性心内膜炎3例。术前心脏彩超提示：前叶病变27例,前叶 后叶病变17例;二尖瓣重度反流19例,中度至重度14例,中度反流9例;42例患者均在全身麻醉低温体外循环下应用“缘对缘”联合人工瓣环修复术进行二尖瓣成形术。术中应用250mL注射器向左心室注冰盐水观察评价成形后二尖瓣反流情况,脱离体外循环后经食管超声心动图观察成形结果。分别测量术前及术后二尖瓣反流面积、二尖瓣开口面积、左房内径及左室舒张末期内径,左室射血分数,应用t检验,研究手术前后二尖瓣反流、心脏大小变化、心功能改善情况。检验水准α=0.05。结果 全组无死亡病例,出院时心脏功能(NYHA分级)I级32例,Ⅱ级10例。随访39例,随访时间1-60(24.6±18.2)个月。超声心动图提示：术前二尖瓣反流面积为11.0cm₂±3.8cm₂,术后1年无或微量反流13例,轻度反流17例,轻度至中度反流9例,轻度二尖瓣狭窄1例,反流面积为4.1cm₂±1.4cm₂;术前二尖瓣开口面积4.14 cm₂±1.54cm₂,术后一年为3.58 cm₂±1.10cm₂;术前左心房内径为48.6mm±12.4mm,术后1年为36.5 mm±9.4mm;术前左心室舒张末径为64.3 mm±11.4mm,术后1年为50.6 mm±7.6mm;术前左心室射血分数为54.6%±6.2％,术后1年提高为63.4%±4.0％。结论“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全手术方法安全、有效,可获得良好的治疗效果。     

Series of transcatheter valve‐in‐valve implantations in high‐risk patients with degenerated bioprostheses in aortic and mitral position

Objectives: We report our experience with transcatheter valve‐in‐valve implantations in patients with degenerated bioprostheses in aortic and mitral position. Background: Xenograft degeneration is a potential problem after biological valve replacement. Reoperation remains the gold standard with very good short‐ and long‐term results. In selected patients not suitable for surgery however, interventional techniques for valve implantation and repair may be valuable alternative treatment options with regard to the good results of transcatheter valve implantation for native aortic valve stenosis. Methods: Five patients presented with significant xenograft degeneration 15.4 ± 5.2 years after aortic (n = 4) and mitral (n = 1) valve replacement. Mean patient age was 82.0 ± 6.5 years and predicted operative mortality was 55.8% ± 18.9% (logistic EuroSCORE). Transcatheter valve‐in‐valve implantation was performed successfully through a transapical access in all patients. A 23‐mm Edwards Sapien valve was deployed into the degenerated valve prosthesis. Results: Mean transvalvular gradients were reduced from 31.2 ± 17.4 to 19.0 ± 12.4 mm Hg in aortic and from 9 to 3 mm Hg in mitral position without significant regurgitation in any of these patients. Two patients died within 30 days due to low cardiac output and acute hemorrhage, respectively, one of whom presented with a EuroSCORE of 88.9%. Conclusions: With growing need for reoperative valve replacement in elderly patients with disproportional operative risks, transcatheter valve‐in‐valve implantation in aortic and mitral position offers an alternative treatment option. Although valve function after transcatheter implantation was good in all patients, two high risk patients died in the postoperative period due to their significant comorbidities, underscoring the bail‐out character of this procedure. © 2010 Wiley‐Liss, Inc.     

Core valve embolization: Technical challenges and management

Transcatheter Aortic Valve Implantation with the Core Valve self expanding prosthesis can be complicated by hemodynamic instability in cases of low deployment (implant failure). The management of a low implant may necessitate repositioning the prostheses with the help of a snare catheter. Snaring can however be complicated by embolization of the prosthesis which presents a series of technical challenges that need to be addressed. We have discussed the technical issues and the approach to address them successfully in a systematic manner to ensure optimal procedural and patient outcomes. © 2011 Wiley Periodicals, Inc.     

Valve‐in‐valve implantation with a 23‐mm balloon‐expandable transcatheter heart valve for the treatment of a 19‐mm stentless bioprosthesis severe aortic regurgitation using a strategy of “extreme” underfilling

We report a case of valve‐in‐valve (ViV) implantation by transfemoral approach with a 23‐mm balloon‐expandable prosthesis inside a stentless 19‐mm acutely degenerated bioprosthesis, using a strategy of “extreme” underfilling. A 74‐year‐old patient presented to our institution in cardiogenic shock. An initial transesophageal echocardiography (TEE) showed severe central aortic regurgitation (AR) due to a torn leaflet. She was deemed inoperable and considered for urgent transcatheter aortic valve replacement. Given the fairly small true internal diameter, a strategy of 3‐cc underfilling of a 23‐mm transcatheter heart valve (THV) was planned. However, the final implantation was performed with 5‐cc underfilling due to the incapacity to deliver the entire amount of fluid contained in the inflation syringe. TEE guidance confirmed the successful positioning and deployment of the prosthesis, with no AR and a mean gradient of 25 mm Hg. While implantation of a smaller prosthesis (20 mm) was debated during the Heart Team discussion, the risk of valve embolization due to inadequate anchoring inside the stentless prosthesis led to the selection of a 23‐mm THV. At 6‐month follow‐up, the patient was in NYHA class I, with no AR and a mean gradient of 28 mm Hg. We report for the first time the use of in vivo THV with 5‐cc underfilling with no acute or short‐term structural failure, and the first ViV implantation by transfemoral approach with a 23‐mm balloon‐expandable prosthesis inside a stentless 19‐mm bioprosthesis. The current report presents the challenges related to ViV implantation inside a small stentless bioprosthesis and offers practical ways to overcome them. © 2014 Wiley Periodicals, Inc.