2021 Scientific Sessions

Title

Explantation of an Implantable Left Ventricular Assist Device following Successful Percutaneous Repair of Severe Degenerative Mitral regurgitation

Introduction

Implantation of left ventricular assist device (LVAD) promotes reverse remodeling of myocardium through left ventricular unloading. (1) LVAD implantation has been used as bridge to transplant, recovery, or as destination therapy. Several studies have shown possibility myocardial recovery and LVAD explantation with survival benefits in select populations. (2) We report case of patient with LVAD who underwent percutaneous mitral valve repair for treatment of severe mitral regurgitation that led to successful LVAD explantation.

Clinical Case

65-year-old man with end stage heart failure status post LVAD (HeartMate2, Abbott, North Chicago, IL, USA) presented with significant improvement in left ventricular function. When being evaluated for possible LVAD explantation, he was noted to have severe anteriorly directed mitral regurgitation due to a large flail P2 segment of posterior leaflet. Surgical mitral valve correction was felt to pose prohibitive risk so patient was referred for percutaneous mitral valve repair.

RFV access was obtained and transseptal puncture was performed under fluoroscopic and echocardiographic guidance. A supportive wire was placed in left atrium and 24F steerable guide was advanced into left atrium. Through this, Mitraclip NTR (Abbott Vascular, North Chicago, IL, USA) was advanced into left atrium and directed toward mitral valve. Clip was advanced through center of mitral valve, clip arms were opened and withdrawn to contain A2 and P2 segments of anterior and posterior leaflets. Grippers and clip arms were closed resulting in significant reduction in mitral regurgitation but there was large residual jet lateral to clip. Clip was deployed and second clip was advanced through lateral portion of mitral valve in similar fashion. Grippers and clip arms were closed resulting in further reduction in mitral regurgitation but there was large residual jet between 1^st and 2^nd clips. 2^nd clip was deployed, third clip was advanced through mitral valve at area between two deployed clips. Arms of the third clip were opened and withdrawn to contain anterior and posterior leaflets between two clips. Grippers and clip arms were closed resulting in mild residual mitral regurgitation and mean mitral gradient of 3 mmHg, 3^rd clip was deployed. Steerable guide was withdrawn. Iatrogenic atrial septal defect was closed with12mm septal occluder device (ASO, Abbott Structural, North Chicago, IL, USA) to prevent right-to-left shunting. Patient had uneventful recovery. Three months later, he underwent successful explantation of LVAD.

Discussion

In patients with endstage left ventricular systolic heart failure, LVAD offers significant symptom improvement and mortality benefit. In certain patients, left ventricular recovery is possible and LVAD explantation can be considered. In the patient described, significant myocardial recovery had occurred after LVAD implantation, but residual severe mitral regurgitation made LVAD explantation unlikely to be successful. In this situation, percutaneous mitral valve repair offers a minimally invasive therapy that can improve left ventricular hemodynamics and ultimately improve the likelihood of successful LVAD explantation. To our knowledge, this is the first report of percutaneous mitral valve repair in patient with LVAD that subsequently underwent successful LVAD explantation.