MitraClip XTR Research Articles

Acute type B aortic dissection following transcatheter mitral valve edge-to-edge repair: a case report

Abstract Background Transoesophageal echocardiography is rarely reported as a possible cause of aortic dissection during the transcatheter edge-to-edge repair procedure. Herein, we present a case of type B aortic dissection following the transcatheter mitral valve edge-to-edge repair procedure, most likely related to the transoesophageal echocardiography probe. Case summary A 68-year-old Chinese man complained of exertional dyspnoea lasting over 2 years and had been diagnosed with severe mitral regurgitation. He was admitted to our hospital for the treatment of severe mitral regurgitation with transcatheter edge-to-edge repair. One MitraClip XTR (Abbott Vascular) was successfully implanted under the guidance of active transoesophageal echocardiography, and the mitral regurgitation became trace. However, the patient complained of persistent back pain after the treatment, and computed tomography angiography revealed a type B aortic dissection in the descending aorta. After 2 weeks of unsuccessful conservative treatment, he successfully underwent endovascular stenting and was discharged from the hospital. The patient recovered well and remained event free during the 6-month follow-up. Discussion Herein, we presented a rare complication following transcatheter mitral valve edge-to-edge repair that was most likely related to the transoesophageal echocardiography probe—type B aortic dissection. We postulated that repetitive flexion of the transoesophageal echocardiography probe led to compression-induced injury to the descending aorta wall at the mid-oesophageal level, which was the most probable aetiology of type B aortic dissection. Although this complication is rare, it is potentially fatal and therefore needs attention.

Contemporary Outcomes Following Transcatheter Edge-to-Edge Repair: 1-Year Results From the EXPAND Study

BackgroundThe third-generation MitraClip NTR/XTR transcatheter edge-to-edge repair system was introduced to assist in leaflet grasping with the longer clip arms of MitraClip XTR and to improve ease of use with the modified delivery catheter. ObjectivesThe EXPAND study evaluated contemporary real-world outcomes in subjects with mitral regurgitation (MR) treated with the third-generation MitraClip NTR/XTR transcatheter edge-to-edge repair system. MethodsEXPAND is a prospective, multicenter, international, single-arm study that enrolled patients with primary MR and secondary MR at 57 centers. Follow-up was conducted through 12 months. Echocardiograms were analyzed by an echocardiographic core laboratories. Study outcomes included: MR severity, functional capacity measured by New York Heart Association functional class, quality of life measured by Kansas City Cardiomyopathy Questionnaire, heart failure hospitalizations, all-cause mortality. Results1,041 patients were enrolled from April 2018 through March 2019, of which 50.5% had primary or mixed etiology. Implant success was 98.9%; 1.5 ± 0.6 clips were implanted per subject. Significant MR reduction from baseline (≥MR 3+: 56.0%) to 30 days (≤MR 1+:88.8%) was maintained through 1 year (MR ≤1+: 89.2%). A total of 84.5% and 93.0% of subjects in primary MR and secondary MR, respectively, had ≤1+ MR at 1 year. Significant improvements were observed in clinical outcomes (New York Heart Association functional class I/II in 80.3%, +21.6 improvement in Kansas City Cardiomyopathy Questionnaire score) at 1 year. All-cause mortality and heart failure hospitalizations at 1 year were 14.9% and 18.9%, respectively, which was significantly lower than previous studies. ConclusionsThe study demonstrates treatment with the third-generation system resulted in substantial reduction of MR in a contemporary real-world practice, compared with the results of earlier EVEREST and COAPT trials.(The MitraClip® EXPAND Study of the Next Generation of MitraClip® Devices [EXPAND]; NCT03502811)

Defibrillation lead damage in a patient with MitraClip XTR device in tricuspid position.

Defibrillation lead damage in a patient with MitraClip XTR device in tricuspid position.

Acute changes in mitral valve geometry after percutaneous valve repair with MitraClip XTR by three-dimensional echocardiography.

Mitral valve (MV) repair with MitraClip system is a safe treatment option for high-risk patients with significant mitral regurgitation (MR). We aimed to characterize, by three-dimensional echocardiography (3D-E), changes occurring in MV after implantation of third generation MitraClip XTR device, with specific reference to the underlying MR mechanism (functional vs degenerative, FMR vs DMR). We prospectively enrolled 59 patients, who underwent intra-procedural 3D-E before and after device deployment. Three-D datasets were analyzed off-line, using a dedicated semiautomatic software, to obtain parametric quantification of mitral anatomy. Post-procedural MR of mild or lesser degree was achieved in 40 patients (68%), with no differences between FMR and DMR (p 0.9). After MitraClip XTR implantation, the FMR group experienced an immediate annular resizing, with reduction of antero-posterior diameter (p 0.024) and sphericity index (p 0.017), next to a recovery of physiological saddle-shape, defined by lower non-planar angle (p ≤0.001) and higher annulus height to commissural width ratio (p ≤0.001). On the opposite, the DMR group revealed a significant decrease of maximum annular velocity (p 0.027), addressing a mechanic effect of the device deployment. Finally, baseline anterior mitral leaflet angle was found as an independent predictor of acute procedural result (OR 6.7, [CI 1.01-44.33], p 0.049). MitraClip XTR implantation acts in restoring the original mitral geometry, with distinctive effects according to MR mechanism. Three-D parametric quantification of MV sheds new light on changes occurring in the valvular apparatus, and helps identifying possible new predictors of acute procedural success.

MitraClip NTR vs XTR system for transcatheter tricuspid valve repair of tricuspid regurgitation

Abstract Background Transcatheter tricuspid valve repair (TTVr) is a novel modality for treatment of severe tricuspid regurgitation (TR) in patients at high surgical risk. So far, the most frequently used system is the MitraClip® providing two different clip types (NTR vs XTR). Purpose To compare XTR vs NTR clip systems for TTVr regarding safety, feasibility, and effectiveness. Methods 35 consecutive high-risk patients (78.4±7.9 years, EUROScore II 10.7±10.8%, STS Score 7.9±4.1) with symptomatic TR were treated using the MitraClip® system between 2017–2020. with an NTR (N=18, 51.4%) or XTR (N=17, 48.6%) system. The primary outcome was successful TTVr with TR reduction of ≥1 grade with no mortality, single leaflet device attachment (SLDA), or conversion to surgery until hospital discharge. At 30-day follow-up, TR severity grade and NYHA functional class were assessed. Results We found more severe initial TR grades in the XTR group compared to the NTR group expressed with wider TR V. contracta (14.8±4.3 vs 11.1±3.8 mm, p=0.011), larger EROA (0.99±0.4 vs 0.72±0.3 cm2, p=0.032), wider coaptation depth (9.6±2.8 vs 7.3±0.4 mm, p=0.036) and V. cava inferior (30.7±3.6 vs. 25.8±6.4 mm in NTR, p=0.013). 5 patients (29.4%) in the XTR and 3 patients (16.7%) in the NTR group presented initially with torrential TR. No significant differences were observed for clinical characteristics, comorbidities, co-medication, laboratory parameters or initial NYHA functional class (3.0±0.5 in NTR vs 3.2±0.4 in XTR, p=0.45). TTVr was safe with no intraprocedural deaths, emergency surgery or major vascular complications. Duration of the procedure and fluoroscopy did not differ. Both, NTR and XTR system led to procedural success in 72.2% (N=13) and 76.5% (N=13), respectively. At discharge, a significant reduction of initial TR grade was observed in both groups (2.4±0.9 in NTR and 2.3±0.9 in XTR, p<0.001) with a tendency of greater mean reduction in the XTR group (1.9±1.0 vs. 1.3±0.9, p=0.09). All 5 patients with torrential TR in the XTR group (100%) and just 1 patient (33.3%) in the NTR group achieved the primary outcome. At 30-day follow-up, overall SLDA rate was 22% vs 17.6% for NTR and XTR, respectively. However, these cases were attributed to very high risk patients with poor anatomy. Mortality rate was 11.1% in NTR vs 5.9% in XTR group (p=0.59). Achieved reduction of TR was maintained in both groups (2.6±0.9 in NTR and 2.8±0.9 in XTR, p<0.001). Also, improvement of NYHA functional class was seen (2.5±0.5, p=0.001 in NTR and 2.9±0.6, p=0.055 in XTR). Conclusion MitraClip® NTR and XTR systems for TTVr of severe TR in high-risk patients are safe and effective leading to a significant reduction of TR and clinical improvement. The XTR system seems to allow successful treatment of more severe TR stages compared to NTR. Funding Acknowledgement Type of funding sources: None.

Acute and Short-term Results of MitraClip XTR vs. PASCAL Transcatheter Valve Repair System for Edge-to-Edge Repair of Severe Tricuspid Regurgitation

Background Novel device developments enable the edge-to-edge treatment of inoperable patients with severe tricuspid regurgitation (TR) and large coaptation gaps. We compared the acute and short-term results of patients treated with the MitraClip XTR vs. PASCAL system. Methods We retrospectively analysed 120 patients (72 pts. MitraClip XTR, 48 pts. PASCAL) treated for isolated severe TR on a compassionate-use basis. Results Mean patient age was 77 ± 8 years and the LaPar risk score was 6.7 ± 1.7 %. Patients in the PASCAL group had a larger coaptation gap and a trend to more severe TR. Procedural success (TR ≤ 2) was achieved in 92 % of patients in each group (XTR group: 66/72, PASCAL group: 44/48). Thirty-day follow-up was available in 94 % of patients. Two patients in the PASCAL group and one patient in the MitraClip XTR group died within 30-days of the procedure. Device complications were observed in 15.3 % of patients in the XTR group and in 10.4% of patients in the PASCAL group. There was a trend for a more pronounced reduction of vena contracta width in the PASCAL group compared to the XTR group. Tricuspid repair was associated with a comparable improvement in NYHA functional class and 6-minute walking distance in both groups. Conclusion The PASCAL and the MitraClip XTR system appeared to be highly efficacious in treating patients with severe TR with a comparable rate of device complications in both groups but a trend for a more pronounced reduction of vena contracta width in the PASCAL group.

Percutaneous edge-to-edge repair in the setting of a severe systemic tricuspid regurgitation complicating a congenitally-corrected transposition of great arteries

This study sought to report the specific considerations and implications of percutaneous edge-to-edge repair in one case of severe systemic tricuspid regurgitation (STR). In congenitally-corrected transposition of great arteries (ccTGA) tricuspid valve results spontaneously in systemic position. In this situation, progressive STR and systemic right ventricular (SRV) dysfunction are frequently observed, leading ultimately to altered functional capacities and pulmonary edema. In this setting surgical valve repair or replacement is challenging given the underlying SRV failure, therefore heart transplant is usually preferred. However, recent studies have underlined the reliability of edge-to-edge repair for secondary severe tricuspid and mitral regurgitation. Few data are currently available concerning the percutaneous management of STR. We report about the case of a 59 year-old man presenting with dyspnea and mild peripheral edema. He was known for non-operated ccTGA with SRV ejection fraction (EF) of 25%, and severe STR, defined as an effective regurgitant orifice area of 40 mm 2 . The patient was in theory eligible for heart transplant but a percutaneous approach was first attempted. The procedure was performed under general anesthesia, transesophageal echocardiography guidance and through a femoral vein route. A MitraClip XTR device (Abbott Vascular, Santa Clara, CA) was successfully implanted between the septal and the anterior leaflets, without any complication ( Fig. 1 ). After the procedure the STR improved dramatically from grade IV to I. After 2 years follow-up the patient is still asymptomatic and free from severe STR, concomitantly SRV EF improved up to 32% under optimal medical treatment. Percutaneous edge-to-edge therapy of STR in ccTGA seems to be feasible, safe and effective to reduce regurgitation grade, to limit SRV dilatation and to improve patient symptoms.

Short-Term Clinical Outcomes of Transcatheter Tricuspid Valve Repair With the Third-Generation MitraClip XTR System.

The aim of this study was to assess 30-day outcomes of transcatheter edge-to-edge repair with the MitraClip XTR for significant tricuspid regurgitation (TR), relative to baseline coaptation gap sizes (CGS). Transcatheter edge-to-edge repair using the MitraClip NT for patients with significant TR is safe and efficacious; the utility of the MitraClip XTR is unknown. Patients with significant, symptomatic TR treated at a single site between April 2018 and December 2019, with consent and with complete data, were included (n=50). Baseline and 30-day echocardiograms were assessed by an echocardiography core laboratory. Patients were divided into 3 subgroups on the basis of site-assessed CGS: subgroup I (< 7mm), subgroup II (7 to 10mm), and subgroup III (>10mm). Technical success of the MitraClip XTR implantation was 100% (88% in the septal-anterior position) using a median of 2 clips (interquartile range: 1 to 2). At 30days, single-leaflet detachment was noted in 3 patients (6%), with no instances of device embolization. TR was reduced by 1 grade in subgroup I and by 2 grades in subgroups II and III. New York Heart Association functional class was reduced by 1 class in all 3 subgroups. The 6-min walk distance increased in subgroup I (+115 m; p=0.014) and subgroup II (+31.5 m; p=0.028) but not subgroup III (+50 m; p=0.999). A CGS of≤8.4mm was predictive of a reduction to moderate or less TR. MitraClip XTR implantation is a safe, effective treatment for a wider range of CGS in patients with symptomatic, significant TR than prior device iterations. All patients showed improvement in New York Heart Association functional class, and those with CGS<10mm also experienced improved functional capacity.

Percutaneous edge-to-edge repair of severe mitral regurgitation using the MitraClip XTR versus NTR system.

BackgroundTranscatheter mitral valve repair (TMVR) has shown to improve symptoms and functional capacity in patients with severe mitral valve regurgitation (MR). Novel device developments provide the technology to treat patients with complex anatomies and large coaptation gaps. Nevertheless, the question of superiority of one device remains unanswered. We aimed to compare the MitraClip XTR and MitraClip NTR system in a real world setting.HypothesisTMVR with the MitraClip XTR system is equally effective, but associated with a higher risk of leaflet injury.MethodsWe retrospectively analyzed peri‐procedural and mid‐term clinical and echocardiographic outcomes of 113 patients treated for severe MR between March 2018 and August 2019 at the University Hospital of Munich.ResultsPostprocedural MR reduction to ≤2+ was comparable in both groups (XTR: 96.1% vs. NTR: 97.6%, p = .38). There was a significant difference in a composite safety endpoint of periprocedural Major adverse cardiac and cerebrovascular events (MACCE) including leaflet injury between groups (XTR 14.6% vs. NTR 1.7%, 95% CI [2.7, 24.6], p = .012). After a median follow‐up of 8.5 (4.4, 14.0) months, durable reduction of MR was confirmed (XTR: in 91.9% vs. NTR: 96.8%, p = .31) and clinical and symptomatic improvement was comparable in both groups accordingly.ConclusionWhile efficacy was comparable in both treatment groups, patients treated with the MitraClip XTR systems showed more events of acute leaflet tear and single leaflet device attachment (SLDA). A detailed echocardiographic assessment should be done to identify risk candidates for acute leaflet injury.

Treating Mitral Valve Prolapse in Barlow's Disease by Creation of a Medial MitraClip Bridge and a "New" Lateral Orifice: Rationale for MitraClip NTR Adoption.

Percutaneous mitral valve repair with MitraClip XTR (Abbott Vascular) has been proposed in patients with Barlow's disease, as the extended length of the MitraClip XTR may facilitate "grasping" and limit the number of clips. However, the design of the MitraClip XTR includes arms that 3 mm longer than the NTR device as well as 2 additional frictional elements, and requires a patient selection based mainly on mitral valve tissue quality. We summarize our rationale for using the shorter and smaller MitraClip NTR in patients with Barlow's disease.

Comparison of transcatheter tricuspid valve repair using the MitraClip NTR and XTR systems

BackgroundTranscatheter tricuspid leaflet repair (TTVr) using the MitraClip is a promising option for patients with severe tricuspid regurgitation (TR) and heart failure. However, no comparative studies of the NTR and XTR systems have been reported. ObjectivesThe aim of this study was to assess the relative efficacy, safety, and clinical outcomes of patients with severe TR treated with the MitraClip NTR and XTR systems. MethodsForty consecutive patients with severe TR underwent TTVr. The primary outcome was procedural success, with NYHA functional class, TR grade and major adverse cardiac and cerebrovascular events (MACCE) assessed at 30-day follow-up. ResultsThe majority of patients had functional TR and a greater proportion of XTR patients had torrential TR with larger coaptation gaps. Procedural success was achieved in 70% vs 80% in the NTR and XTR cohorts. Single leaflet device attachment was equal in both groups (5%). At 30-day follow-up, 70% vs 85% of NTR and XTR patients were in NYHA Class I/II. The mean reduction in TR grade was greater in the XTR group (1.5 ± 0.3 vs 2.3 ± 0.4, p–0.012). In patients with torrential TR at baseline, 55% in the XTR group achieved TR ≤ 2+ compared to none in the NTR group (p < 0.001). ConclusionsIn this first study comparing the MitraClip NTR and XTR systems for TTVr, we found both to be safe and effective, while the XTR system allowed treatment of larger coaptation gaps, greater mean reduction in TR grade, with more effective reduction of torrential TR.

3-Dimensional assessment of tricuspid annular geometry after percutaneous edge-to-edge repair in patients with severe tricuspid regurgitation

Abstract Background Transcatheter tricuspid valve repair (TTVR) using edge-to-edge leaflet therapy (E2E) has evolved as a feasible therapy to treating severe tricuspid regurgitation (TR). The TRILUMINATE trial using the new TriClip NT has shown promising clinical and functional improvements. However, the 3rd generation MitraClip XTr (Abbott Structural Heart, Santa Clara, CA, USA) has a broad off-label experience in the European Union to address tricuspid TR with wider gaps. There is insufficient data on the secondary effects of E2E on tricuspid annular geometry. The aim of this study was to address this lack of knowledge by evaluating the acute effects of E2E using the MitraClip XTr. Methods We retrospectively analyzed the imaging data of procedures using the MitraClip XTr to treat severe symptomatic TR at our Institution in 2018. Tricuspid annular geometry was assessed before and immediately after clip implantation by 3D TEE analysis of biplane and manual and automated volume data. Results During 2018, 69 patients were treated for severe TR using a transcatheter approach. In 61 patients, E2E was used, in 58 patients the MitraClip XTr was utilized (Pascal: n=3, Edwards Lifesciences, Irvine, CA, USA). Mean age was 79.0 years ± 6.4. Percutaneous TTVR using the MitraClip XTr significantly decreased the diastolic septal-lateral diameter (S/L: 4.1±0.7cm vs. 3.6±0.7cm; p&amp;lt;0.001), annulus area (14.9±6.7 vs. 12.8±6.2 cm2; p&amp;lt;0.001) and annulus perimeter (14.7±25.0 vs. 13.8±24.4 cm; p&amp;lt;0.001) whereas the diastolic anterior-posterior diameter was not significantly affected (A/P: 4.5±1cm vs. 4.4±0.8cm; p=0,45). Conclusions Percutaneous TTVR using MitraClip XTr showed significant changes in TV annulus geometry by focal perimeter and area reduction. This highlights a new mechanism of E2E therapy through indirectly adressing the dilated annulus in patients with severe TR. Annulus geometry by TOE, 3D- and autoMPR Funding Acknowledgement Type of funding source: None

Incidence of intravascular hemolysis after transcatheter mitral valve repair

Abstract Background Chronic subclinical intravascular hemolysis is a common complication after valve replacement associated with worse prognosis, occurring in up to 80% of patients after mitral valve surgery. While serious intravascular hemolysis after MitraClip implantation has been reported anecdotally, data on the impact of transcatheter mitral valve repair on the prevalence of subclinical hemolysis are lacking. Methods and results From August 2017 to November 2019, 77 patients with high perioperative risk and moderate-to-severe or severe mitral regurgitation were prospectively enrolled in a single-center trial. All participants were treated with transcatheter edge-to-edge mitral valve repair using the MitraClip NT, NTR or XTR system. Before and three months after the procedure, all patients underwent comprehensive clinical assessment including laboratory measurement of hemoglobin, haptoglobin and lactic acid dehydrogenase in venous blood samples. Presence of subclinical intravascular hemolysis was defined as hemoglobin &amp;lt;13.8 g/dl for males or &amp;lt;12.4 g/dl for females, haptoglobin &amp;lt;65 mg/dl and lactic acid dehydrogenase &amp;gt;250 U/l. Levels of the hemolysis marker haptoglobin significantly decreased three months after the intervention (127±71 mg/dl at three months vs. 158±73 mg/dl at baseline, p&amp;lt;0.001), accompanied by an increase in lactic acid dehydrogenase (251±88 U/l vs. 222±55 U/l, p&amp;lt;0.01), implying the induction of intravascular hemolysis by transcatheter mitral valve repair. Higher residual mitral regurgitation was associated with lower haptoglobin levels three months after mitral valve repair (p&amp;lt;0.05), hinting that shear stress caused by regurgitation flow is the primary mechanism for hemolysis after MitraClip implantation. Concurrently, we observed a trend towards an increase in the presence of subclinical intravascular hemolysis (9.1% at three months vs. 3.9% at baseline, p=0.289). Hemoglobin levels remained unchanged (12.1±1.5 g/dl at three months vs 12.3±1.8 g/dl at baseline, p=0.107). No patient needed treatment for intravascular hemolysis. Conclusion Transcatheter edge-to-edge mitral valve repair in a high-risk collective is associated with the induction of hemolysis. Yet, prevalence of subclinical intravascular hemolysis is low when compared to mitral valve surgery, emphasizing the good safety profile of minimal-invasive mitral valve therapy. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): ReForM-B research grant, University of Regensburg

Delayed Mitral Leaflet Perforation in a Tethered Valve After MitraClip XTR Implantation.

A 63-year-old patient with Chagas disease and dilated cardiomyopathy was recommended for percutaneous mitral valve repair with MitraClip by our valve team. Despite cardiac resynchronization therapy 8 years before and optimal medical treatment, the patient was in New York Heart Association functional

Percutaneous mitral valve repair in adults with congenital heart disease: Report of the first case-series.

Systemic atrioventricular valve regurgitation (AVVR) is frequently encountered in adults with congenital heart disease (CHD). Surgical intervention is the mainstay of therapy, but in a specific high-risk subset, percutaneous valve repair might offer a lower-risk alternative. Three patients with complex CHD and severe symptomatic AVVR underwent percutaneous mitral valve repair at a single center. All were deemed to be high-risk for surgery by a multidisciplinary CHD team and provided informed consent for the compassionate use of the MitraClip (Abbott, Santa Clara, CA). Three-dimensional heart models were generated for the procedure, which was performed by an adult CHD cardiologist (who provided imaging support) and an interventional cardiologist with expertise in CHD and percutaneous mitral valve repair. The first case was a 39 year-old-woman with [S,L,D] dextrocardia, double outlet right ventricle, mild tricuspid hypoplasia, and a secundum atrial septal defect, who was palliated at age 35 with a right bidirectional Glenn and later developed severe, symptomatic mitral regurgitation, and underwent placement of one MitraClip XTR device. Two patients with L-loop transposition of the great arteries each successfully underwent placement of two MitraClip XTR devices; one patient had a single-leaflet detachment of one of the clips with no change in regurgitation or clip position on follow-up. All patients had significant reduction of AVVR and improvement in NYHA functional class. Percutaneous atrioventricular valve repair in adults with CHD is feasible with the MitraClip but requires significant preprocedural planning and a multidisciplinary team that combines CHD and interventional therapeutic expertise.

Percutaneous mitral valve repair with MitraClip XTR for acute mitral regurgitation due to papillary muscle rupture

Papillary muscle rupture is an infrequent and highly morbid mechanical complication of acute myocardial infarction. Surgical repair or replacement is traditionally considered first-line therapy. However, many of these patients present in extremis with prohibitively high surgical risk. Repair of mitral regurgitation with the MitraClip device (Abbot Vascular, Menlo Park, CA, USA) is an established therapy to treat degenerative and functional mitral regurgitation. We present a case of successful repair of severe mitral regurgitation due to papillary muscle rupture in the setting of acute myocardial infarction. A two-clip strategy resulted in mild residual mitral regurgitation with resolution of cardiogenic shock and refractory hypoxemia requiring veno-venous extracorporeal membrane oxygenation. Six-month follow-up echocardiogram identified durable results with mild mitral regurgitation and left ventricular ejection fraction of 63 %. Our case demonstrates that percutaneous mitral valve repair with MitraClip is a well-tolerated procedure that can provide acute and long-term benefit for patients with acute mitral regurgitation due to papillary muscle rupture who are at prohibitively high surgical risk.<Learning Objective: Our case illustrates the role of MitraClip in acute mitral regurgitation due to papillary muscle rupture in cardiogenic shock as an alternative to surgical intervention in extremely high-risk patients.>

Transcatheter edge‐to‐edge tricuspid repair for recurrence of valvular regurgitation after left ventricular assist device and tricuspid ring implantation

Tricuspid regurgitation in patients with left ventricular assist device (LVAD) has a significant impact on prognosis and quality of life, and its effects on liver and renal function could negatively impact planned heart transplantation. The aim of the present case is to report the feasibility and the clinical impact of tricuspid transcatheter edge‐to‐edge repair in LVAD patients as adjunctive bridge to transplantation strategy. A 59‐year‐old female patient previously treated with LVAD implantation (HeartMate III) and tricuspid valve repair with 32 mm rigid ring (Medtronic Contour 3D) as bridge to transplantation developed recurrence of significant tricuspid regurgitation with right ventricular decompensation needing inotropic support. Preoperative echo showed torrential tricuspid valve regurgitation Effective regurgitant orifice area(EROA 1.4 cm2) with suspicious of partial detachment of the prosthetic ring. The patient was successfully treated with transcatheter edge‐to‐edge repair with the MitraClip XTR device. Tricuspid regurgitation was reduced by 50% (postoperative EROA 0.7 cm2). She remained stable under continuous inotropic support with no other episodes of right ventricular decompensation and was successfully transplanted 30 days after the clipping procedure. Transcatheter treatment of tricuspid regurgitation in a patient with LVAD was an effective strategy to gain time and bridge the patient to heart transplantation.

MITRACLIP XTR VS. PASCAL TRANSCATHETER VALVE REPAIR SYSTEM FOR EDGE-TO-EDGE REPAIR OF SEVERE TRICUSPID REGURGITATION

Edge-to-Edge repair of severe tricuspid regurgitation (TR) is an alternative treatment option for inoperable patients. We compared the acute and short-term results of patients treated with the MitraClip XTR (Abbott Vascular) vs. PASCAL (Edwards Lifesciences) system. We retrospectively analysed 120

1634 3D transoesofageal echocardiography in detection of anterior leaflet laceration during mitraclip implantation

Abstract Background MitraClip is a percutaneous way of treatment of mitral regurgitation. Recent trials demonstrate its value in modifying prognosis of patients with functional mitral regurgitation. During MitraClip implant imaging with 3D TEE is mandatory to guide the procedure and monitoring the results. Unfortunately, laceration of mitral leaflets is a well-described complication of Percutaneous Mitral valve repair by implantation of MitraClip. 3D TEE can be useful even to detect complication of the procedure and in particular leaflets lacerations. Here we describe a case where 3D TEE was capable to recognize and visualize a laceration in the anterior leaflet (AL) and we assume some mechanisms leading to this complication. Methods An 83 years old man with post-ischemic severe functional mitral regurgitation underwent to MitraClip implantation. The mitral valve shows a severe tenting and annulus was deformed and dilated. The procedure was performed under fluoroscopic and 3D TEE guidance (Philips iE33). Due to the large central regurgitation and large coaptation gap, we decide to implant MitraClip XTR, this is the larger device 5 mm longer. Results A single MitraClip XTR was implanted in the central scallop (A2-P2) in the region of the larger jet, after device positioning a further jet was detected in the region of implant and the original jet was unchanged. Using 3D color complete volume and X-plane reconstructions we recognize that the jet originates between the clip and the basal aspects of AL. Without color Doppler in 3D zoom and X plane reconstruction, a continuum solution was suspected in the body of AL but the shadow of the delivery system partially masked the region. After removal of the device, perforation of AL was clearly depicted also with 3D zoom without color Doppler. The patient was surgically treated and inspection confirmed the laceration and shows a worn thin AL. The laceration of AL can be caused by the tension on a thinned tissue carried out by the large device. The severe tethering and annular dilatation with a marked distance between anterior and posterior leaflet at the tip of the device may have been a determinant factor in the tear occurrence. Conclusion 3D TEE can clearly depict lacerations of leaflets during MitraClip implantation. Preoperative extensive analysis of valve geometry and inspection of leaflets searching for a thinned region can avoid intraoperative complications. The distance between leaflets at the expected tips of the MitraClip can be a predictive parameter of tension applied on the leaflets and of the risk of tearing. Abstract 1634 Figure. Image 1

Treatment of Recurrent MR by MitraClip XTR in a Patient With a PASCAL Device

Percutaneous edge-to-edge repair for mitral regurgitation (MR) is an established method to treat MR in patients not eligible for a surgical approach. Although the largest experience has been gathered with the MitraClip system (Abbott, Chicago, Illinois) ([1][1]), with the PASCAL (Edwards