2019 Scientific Sessions

Title Successful percutaneous edge-to-edge mitral valve repair using MitraClip system in a patient with severe mitral annular calcification and diminutive posterior leaflet Introduction Severe mitral annular calcification (MAC) especially involving mitral leaflets represents substantial technical challenge and may even be prohibitive for transcatheter edge-to-edge mitral valve repair. However, multimodality imaging may provide novel approaches to address this technical challenge. Here, we describe a successful case of edge to edge mitral valve repair using MitraClip in a patient with severe MAC extending to posterior leaflet. Clinical Case 89-year-old female with past medical history of chronic kidney disease, moderate aortic stenosis, acute on chronic systolic heart failure with severely reduced ejection fraction status post CRT-D, coronary artery disease presented to our structural heart and valve clinic with progressively worsening shortness of breath on minimal activity, progressive lower extremity swelling and recurrent hospitalizations for decompensated heart failure. Patient was evaluated by multidisciplinary heart team including advanced heart failure team. Transthoracic echocardiogram demonstrated severe eccentric posteriorly directed mitral regurgitation, severe MAC, very diminutive posterior leaflet, effective regurgitant orifice area of 0.6 cm2, regurgitant volume of 80 ml and systolic flow reversal in the pulmonary veins. Transesophageal echocardiogram (TEE) with 3D imaging demonstrated large sessile mass on the left ventricular side of the posterior mitral leaflet likely due to extension of the MAC beyond the mid portion of the posterior leaflet. This caused restriction of the posterior leaflet motion and leaflet malcoaptation causing severe eccentric posteriorly directed mitral regurgitation. Meticulous survey of posterior leaflet demonstrated disease free segment of approximately 8 mm in length that appeared to be adequate for grasping. This was confirmed on multiple views and allowed to implant MitraClip NT in A2-P2 distribution with excellent results and reduction of mitral regurgitation to trace with satisfactory leaflet insertion. Pulmonary vein flow systolic reversal improved and left atrial pressure decreased with grasping. Post procedure recovery was uneventful and patient was discharged next day. She continues to do well at 6 month follow up with mild MR and improvement in the functional class. Frequency of heart failure hospitalization reduced but she continues to have residual dyspnea on exertion secondary to long standing severe non ischemic cardiomyopathy. Discussion Severe mitral annular calcification extending to mitral leaflets offer significant anatomical and technical challenges for transcatheter edge to edge mitral valve repair with MitraClip. Detailed leaflet survey using 3D TEE imaging and multiple views may identify anatomy suitable for successful grasping. As we gain experience, previously prohibitive anatomy can now be successfully treated with MitraClip and can offer incremental clinical benefit to symptomatic patients without surgical options.