Imaging for Transcatheter Mitral Valve Edge-to-Edge Repair for an Unusual Cause of Cardiogenic Shock

HomeCirculation: Cardiovascular ImagingVol. 16, No. 4Imaging for Transcatheter Mitral Valve Edge-to-Edge Repair for an Unusual Cause of Cardiogenic Shock Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBImaging for Transcatheter Mitral Valve Edge-to-Edge Repair for an Unusual Cause of Cardiogenic Shock Zhi-Nan Lu, Qi Chen, Yat-Yin Lam and Guangyuan Song Zhi-Nan LuZhi-Nan Lu https://orcid.org/0000-0002-5095-2013 Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, China (Z.-N.L., Q.C., G.S.). , Qi ChenQi Chen Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, China (Z.-N.L., Q.C., G.S.). , Yat-Yin LamYat-Yin Lam Hong Kong Asia Heart Center, China (Y.-Y.L.). and Guangyuan SongGuangyuan Song Correspondence to: Guangyuan Song, MD, Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Email E-mail Address: [email protected] https://orcid.org/0000-0002-7868-6132 Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, China (Z.-N.L., Q.C., G.S.). Originally published2 Dec 2022https://doi.org/10.1161/CIRCIMAGING.122.014588Circulation: Cardiovascular Imaging. 2023;16Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: December 2, 2022: Ahead of Print An 82-year-old female presented to the emergency department with increasing exertional dyspnea for 2 months and palpitations for 8 hours. She denied fever, chills, or flu symptoms. On examination, she was afebrile, tachycardic (heart rate 130 bpm), and hypotensive (blood pressure, 98/60 mmHg). A cardiovascular examination revealed an irregular heart rhythm, the presence of S3, and a grade 3/6 holosystolic murmur best heard at the apex with radiation to the axilla. Bibasilar crackles and an expiratory wheeze were detected when examining the lungs. A chest X-ray revealed acute pulmonary edema. An electrocardiogram showed atrial fibrillation with a fast-ventricular response and widespread ST segment depression. A transthoracic echocardiogram demonstrated biatrial dilation with severe mitral regurgitation (MR), mild tricuspid regurgitation, and mildly impaired left ventricular systolic function with an ejection fraction of 45%. There were no evidence of ventricular chamber dilation, myocardial hypertrophy, or regional wall motion abnormality. Blood gas analysis suggested hypoxemia with an oxygen partial pressure of 80.8 mmHg and oxygen saturation of 93%. The white blood cell count, basic chemistry panel, erythrocyte sedimentation rate, C-reactive protein levels, and other inflammatory markers were normal. N-terminal brain natriuretic peptide (2548 pg/ml, reference <400 pg/ml) and troponin I (0.07 ng/ml, reference <0.05 ng/ml) levels were elevated. She developed profound hypotension, cool extremities, and confusion shortly after admission and was transferred to the cardiac intensive care unit for endotracheal intubation and mechanical ventilation. The patient's hemodynamics improved significantly by continuous positive pressure ventilation, inotropic drug infusion, intravenous diuretics and digitalis administration. When her condition was stable, the heart rate was around 70 bpm, and ST depression in the electrocardiogram recovered to baseline. A coronary angiogram showed no significant stenosis. Two- and three-dimensional transesophageal echocardiography demonstrated severe MR with significant mitral annulus dilation (24 mm×26 mm), mitral valve prolapse and leaflet perforation (elliptical shape measuring 4.1×5.6 mm at the P1-P2 scallops; Figure 1; Videos S1 and S2).Download figureDownload PowerPointFigure 1. Two- and three-dimensional transesophageal echocardiograms demonstrate the pathophysiology of mitral regurgitation. A, The leaflet prolapse and perforation (white arrow) are shown in a 2-dimensional 5-chamber view. B, Two jets (white arrows) flow back toward the left atrium in the systolic period from prolapse and perforation, respectively. C, The 3-dimensional view shows mitral prolapse and leaflet perforation at the P1–P2 scallops (white arrow). D, The 3-dimensional view with color Doppler shows severe mitral regurgitation caused by mitral prolapse and leaflet perforation at the P1-P2 scallops. E and F, Pulsed wave Doppler shows a reverse systolic pattern of the left (E) and right (F) pulmonary veins. G and H, Three-dimensional TrueVue (EPIQ CVx Ultrasound, Philips, Amsterdam, The Netherlands; G) with color Doppler (H) shows more clearly and intuitively mitral prolapse and leaflet perforation at the P1–P2 scallops (white arrow) leading to severe mitral regurgitation.Because this patient had no history or evidence of infective endocarditis, no previous operations, and no other underlying medical condition that might explain the perforation. Hence, she was considered to have degenerative mitral valve prolapse and native mitral leaflet perforation. Moreover, atrial fibrillation may not only serve as an additional occult culprit of severe MR, but also a trigger for hemodynamical collapse.She was evaluated for surgery but declined because of advanced age, frailty, and hemodynamic instability. High-quality three-dimensional images showed that the total width of the posterior prolapse and leaflet perforation was 18 mm, and the MV area was 5.19 cm2 with mean trans-mitral gradient of 3 mmHg. The details of mitral valve (MV) anatomical characteristics are shown in Figure 1 and Table 1. All these unique features suggest that transcatheter edge-to-edge repair may be a feasible option to correct complex MR.Table 1. The Mitral Valve Anatomic CharacteristicsProlapse locationP2 scallopProlapse width, mm13.9Prolapse gap, mm3.2Leaflet perforation locationElliptical shape at the P1 and P2 scallopsLeaflet perforation size, mm4.1×5.6Anterior leaflet length at A1 scallop, mm20.2Posterior leaflet length at P1 scallop, mm9.7Mitral valve area, cm25.19Mean transmitral gradient, mmHg3Because clipping may extend the perforation during attempted leaflet grasping, it is generally considered that the application of transcatheter edge-to-edge repair therapy alone is not suitable for leaflet perforation. However, with advanced high-quality imaging and excellent catheter control, we proposed 3 percutaneous strategies for this patient (Figure 2).Download figureDownload PowerPointFigure 2. Transcatheter interventional strategies with the MitraClip system for posterior leaflet perforation and prolapse causing mitral regurgitation. A, One clip is used to stabilize the prolapse lesion first and another clip, to cover the perforation. B, The first clip is required to reach the posterior leaflet base and fully cover the whole perforation. The second clip is then placed at the medial prolapse lesion, which should be close to the first clip. C, Two clips are used to repair the prolapse lesions at the medial and lateral sides of the perforation, increasing the stability of the leaflet motion. Then, the perforation is closed with a vascular plug or a septal occluder device.We can use one clip to stabilize the prolapsed lesion first, and another clip to cover the perforation. This strategy will cause residual MR around the second clip (Figure 2A).If the perforation is supposed to be grasped first, the first clip should reach the posterior leaflet base and fully cover the whole perforation. The second clip is placed at the medial prolapse lesion, which is close to the first clip. Moreover, this strategy is expected to be successful with 1 or 2 hits. Multiple grasps will greatly increase the risk of leaflet injury causing more serious MR (Figure 2B).Two clips are used to treat the prolapse lesions at the medial and lateral sides of perforation. Then the perforation is closed with a vascular plug or a septal occluder device. This method may cause stenosis of the MV orifice, and the hemodynamic success may be undermined by severe hemolysis (Figure 2C).1After carefully comparing the benefits and risks of these 3 opinions, we decided to use the first strategy. The first XTR clip was placed at the medial P1-P2 prolapse to stabilize the mitral leaflet motion, and the second XTR was located close to the lateral side of the first clip, which led to the successful closure of the perforation (Figure 3; Videos S3 through S9). Post-procedure, the severity of the MR dropped to mild without mitral orifice stenosis (vena contracta of residual MR=1.55mm, Figure S1; mean MV gradient post procedure=4 mmHg, Figure S2). As expected, although there was still a mild residual MR around the second clip, the patient's blood pressure increased from 90/60 to 120/70 mmHg immediately after the procedure.Download figureDownload PowerPointFigure 3. Transcatheter edge-to-edge repair procedure guided by 2- and 3-dimensional transesophageal echocardiography. A, The first MitraClip XTR is placed at the medial prolapse guided by the 2-dimensional (2D) X-plane view. B, Residual mitral regurgitation (MR) after implantation of the first clip is evaluated by 2D color Doppler echocardiography. C, The position and effect of the first XTR are further confirmed by 3-dimensional (3D) real-time images; the perforation (left white arrow) is next to the first clip (right white arrow). D, Residual MR that occurred after the first clip was implanted is evaluated by 3D color Doppler echocardiography. E, The 2D X-plane view shows the perforation of the second XTR-covered leaflet and the grasped prolapse at the lateral side closing to the second XTR (white arrows). F, Mild residual MR around the second XTR is observed by 2D color Doppler echocardiography. G, The position and stability of the 2 clips (white arrows) are evaluated by 3D real-time images. H, Residual MR after the 2 clips implantation is further evaluated by 3D color Doppler echocardiography. I and J, Pulsed-wave Doppler shows a reverse systolic pattern of the left (I) and right (J) pulmonary veins. K and L, 3D TrueVue (EPIQ CVx, Philips) shows the procedure details after the first (K) and second clips are implanted (L).At the 3-month follow-up, the patient's condition greatly improved with a 6-minute walking distance of 315 m and a Kansas City Cardiomyopathy Questionnaire score of 61.81 points. Repeated transthoracic echocardiogram showed mild residual MR with good device stability (Figure S2, Video S10).The advent of three-dimensional echocardiography has enabled an intuitive visualization of the MV pathophysiological features and the ability to guide the interventional procedures.2 transcatheter edge-to-edge repair is increasingly being utilized in patients with MV prolapse and flail.3 However, little has been reported about their application in patients with MV perforation.4This is the first report of combined MV leaflet prolapse and perforation successfully treated with transcatheter edge-to-edge repair. It demonstrates the following 3 important strategies regarding accurate diagnosis and intraprocedural guidance by advanced high-quality imaging: (1) transesophageal echocardiography is a vital technique to identify the underlying mitral pathology, especially for complex MR; (2) Precise evaluation of defect with two- and three-dimensional transesophageal echocardiography are critical to screen the appropriate patients for percutaneous therapy; (3) To deal with complicated cases, close cooperation between the echocardiographic expert and the interventionalist is pivotal for satisfactory outcome.Article InformationSources of FundingNone.Supplemental MaterialVideos S1–S10Figures S1 and S2Disclosures None.FootnotesSupplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.122.014588.For Sources of Funding and Disclosures, see page 370.Correspondence to: Guangyuan Song, MD, Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Email songgy_anzhen@VIP.163.comReferences1. Panaich SS, Qazi AH, Horwitz PA, Staffey K, Rossen JD. Transcatheter repair of anterior mitral leaflet perforation: deploy, retrieve, redeploy.JACC Case Rep. 2019; 1:689–693. doi: 10.1016/j.jaccas.2019.10.014CrossrefMedlineGoogle Scholar2. Fan Y, Chan JSK, Lee AP. Advances in procedural echocardiographic imaging in transcatheter edge-to-edge repair for mitral regurgitation.Front Cardiovasc Med. 2022; 9:864341. doi: 10.3389/fcvm.2022.864341CrossrefMedlineGoogle Scholar3. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease.Eur Heart J. 2022; 43:561–632.CrossrefMedlineGoogle Scholar4. Addis DR, Law M, von Mering G, Ahmed M. Codeployment of a percutaneous edge-to-edge mitral valve repair device and a ventriculoseptal defect occluder device to address complex mitral regurgitation with leaflet perforation.Catheter Cardiovasc Interv. 2020; 96:1333–1338. doi: 10.1002/ccd.29147CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails April 2023Vol 16, Issue 4 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.122.014588PMID: 36458532 Originally publishedDecember 2, 2022 Keywordscardiogenic shockfemaleimagingmitral valvetranscatheterPDF download Advertisement SubjectsCatheter-Based Coronary and Valvular Interventions