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Internacional Journal of Cardiovascular Sciences. 2015;28(4):338-341
CASE REPORT
Transcatheter Mitral Valve Repair, MitraClip, in a Nonagenarian Patient
with Acute Regurgitation
Denise Castro de Souza Côrtes1,2, Paulo Roberto Dutra da Silva1,3, Antonio Sérgio Cordeiro da Rocha1,3,
Alexandre Siciliano Colafrancheschi1,3, Carolina Garbin Comandulli1, Eduarda Barcellos1
Hospital Pró-Cardíaco – Rio de Janeiro, RJ – Brazil
Fundação de Assistência e Previdência Social do BNDES – Rio de Janeiro, RJ – Brazil
3
Instituto Nacional de Cardiologia – Rio de Janeiro, RJ – Brazil
1
2
Abstract
MitraClip transcatheter implant is a promising option for treating mitral regurgitation (MR) in patients with high
surgical risk. This report describes the case of a nonagenarian patient with acute MR for chordae rupture that,
due to prohibitive surgical risk, underwent a successful MitraClip transcatheter implant.
Keywords: Mitral valve insufficiency; Mitral valve prolapse; Vascular access devices
Introduction
Acute mitral regurgitation (MR) is usually caused by
acute structural abnormalities of the mitral valve, either
by infection causing destruction of the tendinous chordae
or valve leaflet by either spontaneous rupture of the
tendinous chordae or rupture of papillary muscle due to
acute myocardial infarction1.
Acute volume overload on the left ventricle causes
pulmonary congestion and low cardiac output. If this
volume overload is not tolerated, despite full drug
treatment, emergency surgery should be performed1.
These patients, however, face high surgical risk inherent
in the procedure, which can become prohibitive in the
presence of old age and comorbidities 2 . In such
circumstances, non-surgical treatment options, such as
transcatheter mitral repair, appear as less invasive and
lower risk treatment alternatives2.
This report describes the case of a nonagenarian patient
with acute MR and high surgical risk who underwent
successful MitraClip transcatheter implant.
Case Report
Female patient, 94 years old, was admitted to hospital
with dyspnea rapidly progressing to orthopnea
(functional class IV of the New York Heart Association
— NYHA) in the last 45 days; hypertension, type II
diabetes, obesity, hypothyroidism, chronic venous
insufficiency and mitral valve prolapse.
On admission, the patient was diagnosed with severe
MR due to tendinous chordae rupture (Figure 1A and
B). Despite the therapeutic measures adopted, the patient
developed anasarca, severe hyponatremia and
Corresponding author: Denise Castro de Souza Côrtes
Centro Médico Pró-Cardíaco
Rua Mena Barreto, 29 sala 203 – Botafogo – 22271-100 – Rio de Janeiro, RJ – Brazil
E-mail: [email protected]
DOI: 10.5935/2359-4802.20150049
Manuscript received on June 3, 2015; approved on July 14, 2015; revised on July 14, 2015.
Int J Cardiovasc Sci. 2015;28(4):338-341
Case Report
Côrtes et al.
MitraClip and Correction of Acute Mitral Regurgitation
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hypokalemic metabolic alkalosis. Continuous
ultrafiltration and non-invasive ventilation were
indicated. Due to the operative mortality risk of
24.13% by EuroSCORE II and 48.38% by the STS score,
the heart team opted for the MitraClip transcatheter
implant.
Figure 2A
Prolapse of the anterior mitral leaflet
Figure 1A
Severe mitral regurgitation
Figure 2B
Correct positioning of the MitraClip at the center of the
valve orifice
Discussion
Figure 1B
Significant reduction in mitral regurgitation after
MitraClip implant
The procedure, guided by three-dimensional
transesophageal echocardiography (Figure 2A and B),
was uneventful, requiring only the implant of a device.
After the procedure, there was progressive recovery of
spontaneous diuresis and stabilization of nitrogenous
compounds. The patient was discharged in NYHA
functional class II on the fifteenth day after the
procedure.
Mitral valve repair or surgery are
ABBREVIATIONS AND
considered the gold standard treatment for
ACRONYMS
severe MR associated with left ventricular
•LV — left ventricle
dysfunction or symptoms3. The good result
•MR — mitral regurgitation
of surgery in this group of patients is
directly related to the improvement of
•NYHA — New York Heart
Association
symptoms and life expectancy. However,
there is a significant number of patients
with symptomatic MR and severe
comorbidities that place them at high risk of surgical
morbidity and mortality2. If the surgical risk is considered
prohibitive, the patient is relegated to clinical treatment.
It is estimated that about half of symptomatic patients
with severe MR do not undergo surgery. For those
patients without a good therapeutic option, transcatheter
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Côrtes et al.
MitraClip and Correction of Acute Mitral Regurgitation
mitral valve repair becomes a viable therapeutic
alternative, especially with the implant of MitraClip,
which is analogous to the surgical procedure of creating
a dual orifice.
The MitraClip transcatheter implant, which enables a
less invasive approach to severe MR, is supported by the
study EVEREST II4. In this trial, 279 patients with severe
MR, with bad coaptation of the middle part of the anterior
or posterior leaflet were randomized for MitraClip
transcatheter implant or mitral valve surgery (valve
repair or replacement). At the end of 48 months of
follow-up, mortality was similar in both groups of
patients: 17.4% in the MitraClip and 17.8% in the surgery
(p=0.91). There was no significant difference between the
groups regarding the percentage of severe residual mitral
regurgitation: 21.0% in the MitraClip and 20.2% in the
surgery (p=0.74). However, the need for early or late
surgical intervention or reoperation was significantly
higher in the MitraClip group (25.0% vs. 5.0%; p<0.001)4.
In a substudy of EVEREST II4, which involved high-risk
patients, with an estimated operative mortality above
12.0%, of which 56.0% had functional MR and 44.0% had
degenerative MR, there was decreased MR severity,
improvement of symptoms, reversed remodeling,
reduced hospitalizations, improved in quality of life and
survival at 12 months in patients treated with MitraClip
compared to the control group5.
In a study involving 127 patients with severe degenerative
MR and prohibitive surgical risk, the implant surgery
was successful in 95.0% of the cases, survival at one year
was 74.0%, there was improvement in functional class,
quality of life, left ventricular (LV) remodeling index and
reduced recurrent hospitalizations for heart failure6.
In the ACCESS-US study (A two phase observational
study of the MitraClip system in Europe) 7, which
analyzed 567 patients, the implant success rate was 99.6%.
Thirty-day mortality was 3.4% and, in 12 months, it was
19.0%. In one year, open mitral surgery was necessary in
6.3% of patients, 3.4% required another MitraClip to treat
residual MR and the incidence of MR 3 or 4+ was 21.0%.
Int J Cardiovasc Sci. 2015;28(4):338-341
Case Report
Among the survivors, 71.0% were in NYHA functional
class I or II, with better performance in the 6-minute walk
test and quality of life scores7.
Surgical repair after MitraClip implant surgery is feasible,
although a higher degree of valvular fibrosis after the
clip is implanted may involve valvar exchange8. In the
study EVEREST II4, 37 patients out of 178 who have had
MitraClip implanted required surgery in 12 months.
Mitral valve repair was possible in 20 and valve
replacement was possible in 17 patients. Clip removal
becomes more difficult after 30 days of implantation due
to fibrosis and scarring of the leaflets. Involvement of the
anterior leaflet is predictive of need for valvar
replacement9.
Therefore, MitraClip transcatheter implant is an
alternative that should be considered for patients at high
or prohibitive surgical risk and anatomy favorable to the
procedure, as in the case reported here.
In the last guideline for valvular diseases of the American
Heart Association and American College of Cardiology3,
mitral valve transcatheter repair is considered as IIB
recommendation class, evidence level B3.
To maximize the clinical success of this procedure the
participation of a multidisciplinary team (heart team) is
essential. A careful pre-assessment of the mitral valve
anatomy and function, cavity dimensions, biventricular
functions, pulmonary artery pressures and any
concomitant aortic or tricuspid valve disease, in addition
to the knowledge of the coronary anatomy and
comorbidities are key components in the process.
Potential Conflicts of Interest
This study has no relevant conflicts of interest.
Sources of Funding
This study had no external funding sources.
Academic Association
This study is not associated with any graduate programs.
Int J Cardiovasc Sci. 2015;28(4):338-341
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