Title:
Severe mitral regurgitation in the setting of prior surgical mitral valve repair with Alfieri stitch treated with a vascular plug and a MitraClip XT
Katherine Rajotte PA-C, Scott M. Chadderdon MD, Howard K. Song MD, PhD, Harsh Golwala MD, Joaquin Cigarroa MD, Grant Burch MD, Firas Zahr MD
Introduction:
In high risk surgical patients with prior surgical Alfieri stitch, recurrent severe mitral regurgitation (MR) can be challenging to address, especially when either the stitch and/or mitral regurgitation is commissural. In cases with favorable anatomy, transcatheter mitral valve (MV) edge-to-edge repair and vascular plug closure of a small regurgitant orifice can be utilized with excellent results.
Clinical Case:
65 y/o male with remote aortic and mitral valve endocarditis treated with surgical aortic valve replacement (SAVR) using a 26mm homograft and MV debridement and suture perforation repair. Four years later he developed severe homograft stenosis and severe MR, and underwent second SAVR (mechanical On-X #21) and MV edge-to-edge repair with an Alfieri stitch at the lateral commissure. Eight years after his second cardiac surgery, he presented with NYHA Class III symptoms and increasing diuretic requirements. Physical exam was significant for a 2/6 axillary holosystolic murmur and separate crescendo-decrescendo flow murmur across the mechanical aortic prosthesis. Further assessment by transesophageal echo (TEE) noted an ejection fraction of 65% and severe complex MR with two significant jets, one arising from the lateral aspect of the A2/P2 scallops that was medial to the Alfieri stitch, and one jet arising lateral to the stitch in the lateral commissure. After multidisciplinary review, the patient was opined to be an extreme risk surgical candidate due to his two prior sternotomies. Transcatheter MV replacement was not an option given prior MV repair with intact Alfieri stitch and lateral commissural mitral regurgitation. Recommendation was made to proceed with percutaneous MV edge-to-edge repair using a MitraClip device and closure of the lateral commissure with a vascular plug. Following transseptal crossing, an Agillis sheath and angled catheter were used to cross the regurgitant orifice lateral to the stitch, and a 10mm Amplatzer II vascular plug was deployed between the lateral commissure and the Alfieri stitch. TEE demonstrated no residual MR lateral to the stitch, but ongoing severe MR arising medial to the stitch from the lateral aspect of the A2/P2 scallops. A MitraClip XT was then applied lateral to A2/P2 with good leaflet capture and reduction in the in degree of MR from severe to mild with a final mean transmitral gradient of 4 mmHg. Patient was discharged in stable condition two days post procedure. At time of 30 day follow up, the patient’s functional status improved to NYHA class II symptoms and TTE demonstrated no residual MR with a mean transmitral gradient of 5.8 mmHg.
Discussion:
This case highlights the use of a MitraClip XT and a 10mm Amplatzer II vascular plug to address severe symptomatic complex MR in an extreme risk surgical patient with a history of prior surgical MV repair with Alfieri stitch.