Tips and tricks to implant a MitraClip in a patient with previous surgical closure of atrial septal defect

Abstract

Percutaneous edge-to-edge mitral valve repair using the MitraClipdevicehasevolvedasanewtoolfortreatmentofmitralvalveregurgita-tion (MVR). The first randomized controlled trial (EVEREST II) com-pared the standard surgical repair/replacement of mitral valve versuspercutaneous repair by MitraClip and demonstrated its superior safetycomparedtosurgicalprocedure,withinferiorefficacyinMVRreduction,but similar improvements in clinical outcomes at 4 years follow-up [1].The guidelines [2,3] on the management of valvular heart disease, pub-lished in 2012 and 2014, suggested to consider percutaneous edge-to-edge mitral valve repair in patients with symptomatic severe MR, con-sidered inoperable or at high surgical risk by “heart team” and thathave a reasonable life expectancy (Class IIb). Percutaneous edge-to-edge mitral valve repair by MitraClip device using trans-septal leftheartcatheterization[4] isbecomingafirst-line treatmentfor function-alMR,whenanatomicalfeaturesaresuitable.Infact,thesepatientsusu-ally show a higher surgical risk and hospital mortality and a longerhospital stay than degenerative MR [5].We describea rarecaseof a61-year-oldmanwithsevere functionalMR, idiopathic dilatative cardiomyopathy and low ejection fraction(30%), in which the MitraClip implantation was very demanding. Healso had arterial hypertension, chronic renal failure on dialysis, moder-ate pulmonary hypertension and previous surgical closure of atrialseptum defect with direct suture. He underwent to automatedcardioverter defibrillator implantation in primary prevention and wasreferred to our hospital for a severe MVR in functional Class IV NYHA.The patient's anterior chest wall revealed a well healed sternotomyscar. The results of his laboratory analysis, including metabolic profileand complete blood count, were normal, with the exception of serumcreatinineandpro-BNPlevelsthatwereelevated.TheECGshowednor-mal sinus rhythm at 78 bpm. The trans-thoracic echocardiogramshowedanincreased diameter of theleft atrium and ventricle with dif-fuse hypokinesia and severe reduction of left ventricular systolic func-tion (Simpson ejection fraction 30%); thickening of the mitral valveleaflets, annulus and subvalvular apparatus and increased diameters oftherightsectionswithslightreductionofrightventricularsystolicfunc-tion (TAPSE 14mm). The color-Doppler demonstrated a severe MR (jetarea 11 cm