Presenter
Samantha Michelle Espinosa, MD, Mayo Clinic Florida, Boston, MA
Samantha Michelle Espinosa, MD1, Abdallah El Sabbagh, M.D.2, Pragnesh Parikh, MD2 and Prajwal Reddy, MD2, (1)Mayo Clinic Florida, Boston, MA, (2)Mayo Clinic Florida, Jacksonville, FL
Title:
TEER The Leaflet
Introduction
Percutaneous interventions for mitral valve regurgitation (MR) continue to improve and expand. Transcatheter edge to edge repair (TEER) is frequently utilized as an alternative to surgical intervention but has the potential for suboptimal results in certain anatomies. Electrosurgical laceration and stabilization of clip (ELASTA-Clip) is an effective percutaneous option for salvaging a failed TEER.
Clinical Case
A 74 year old man with a history of severe MR status post mitral valve (MV) repair with 34mm Edwards Physio II ring via minithoracotomy 3 years prior presented for evaluation of progressive heart failure with preserved ejection fraction and right heart failure symptoms with dyspnea and congestive hepatopathy. A transesophageal echocardiogram (TEE) showed a MV flail central posterior leaflet segment (presumed P2) with severe MR from two separate eccentric jets, preserved left and right ventricular functions, and moderate tricuspid valve regurgitation. TEER and mitral valve in ring (ViR) were considered, and TEER was pursued to avoid risk of left ventricular outflow obstruction (LVOTO). TEER was performed with one MitraClip NTW successfully deployed at A2-P2 with only mild residual MR and mean diastolic gradient 5 mmHg (heart rate 86 beats per minute) on intraprocedural TEE. A new baseline transthoracic echocardiogram (TTE) was obtained on postprocedural day one which demonstrated severe eccentric medially-directed MR. Given improvement in his symptoms, the decision was made to initially manage the patient medically. At clinic follow up, he had recurrence of dyspnea on exertion and peripheral edema similar to before undergoing TEER. After aggressive diuresis and blood pressure control, repeat TEE was performed and demonstrated persistent severe eccentric MR with concern for flail segment laterally adjacent to the MitraClip, and the LV function had declined with an LV ejection fraction 45%. Thus the decision was made to proceed with mitral ViR. Cardiac computed tomography angiography (CTA) was obtained for planning to assess LVOTO risk. The patient subsequently underwent TEE-guided ELASTA-Clip-facilitated ViR implant with 29mm Sapien S3 Ultra Resilia. Access was obtained via bilateral common femoral veins and left common femoral artery for intra-aortic balloon pump support. Transseptal puncture was performed in the inferior-posterior location with Versacross system and the interatrial septum was dilated with 14mm balloon septostomy. Two steerable sheaths guided wires and two 6F JR4 catheters across the MV on either side of the MitraClip, and the ELASTA was performed across the anterior leaflet with resultant torrential MR. The ELASTA setup was disassembled and through one steerable sheath the bioprosthesis was advanced and successfully deployed within the MV ring repair with a final position 30% atrial and 70% ventricular. TEE showed mild periprosthetic regurgitation and no LVOTO. Postprocedural day one TTE showed stably fixed MitraClip on the native posterior leaflet and stable mild periprosthetic regurgitation.
Discussion
TEER and ViR are options for recurrent MR after surgical MV repair. Preprocedure evaluation with TEE and cardiac CTA can help guide the route of percutaneous intervention, and ELASTA-Clip is a safe and effective option for recovering a failed TEER.