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Download Percutaneous Mitral Valve Repair With The MitraClip Device
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CASO CLINICO: PERCUTANEUS MITRAL VALVE REPAIR Dr. Giuseppe Grasssi Direttore UO Cardiologia VENEZIA history and physical exam • 67 yrs old female • no known cardiovascular risk factors, no past medical history • ER admission after 2 hours from symptoms onset (chest pain, first episode) • BP135/80, HR 85 bpm, peripheral blood oxygen saturation 99% (room air), physical exam unremarkable except for mild systolic murmur at the apex, no signs of pulmonary congestion ekg at admission posterior STEMI first invasive pressure tracing: hypotension emergent coronary angiography • despite good angiographic result (TIMI 3 flow, no dissection, no residual thormbus, no apparent thrombus migration, only loss of tiny posterobasal branch) hyoptension & EKG sings of posterior ischemia persist • inotropes started (dopamine 8 mcg/Kg/min) • patient gets restless • rapid onset of pulmonary oedema • need for emergent airway intubation and IABP counterpulsation massive mitral regurgitation, possibly due to papillary muscle rupture CALL THE HEART SURGEONS FOR EMERGERGENT MITRAL VALVE REPAIR! tee revealed papillary muscle flail heart team discussion • indication for MV surgery: • no doubt • surgical risk: very high, Euroscore 24% (female, 67 yrs, recent myocardial infarction, critical conditions [mechanical ventilation, IABP, inotrpes], emergent intervention, open heart surgery) + papillary muscle rupture • but... • OR not available because of other ongoing open heart interevntion what next? heart team discussion • try to stabilize the patient with medical therapy and IABP • wait for OR availability persistent, profound hypotension new heart team discussion • medical therapy and IABP support are insufficient • a “bridge solution” should be found: percutaneus VAD or percutaneous mitral valve repair new heart team discussion: “bridge solutions” • Impella/Tandem Heart: not available at our Institution • ECMO: not possible because perfusionists busy with the ongoing intervention • MitraClip Intervention: device available but serious concerns about anatomical feasibility, procedural time, haemodynamic stability EMERGENT mitraclip intervention • Anatomical feasibility ? papillary muscle flail with large flail gap and width. Coaptation length possibly not a problem. • Procedural time? not predictable, but probably long; major concern given patients’ heamodynamics tee tee emergent mitraclip procedure • despite high risk of procedural failure and intraprocedural death, the decision was taken to go on with the MItraClip intervention • no problems found during initial procedural steps including vascular access site puncture, trans-septal puncture, guiding catheter positioning, and MitraClip device steering towards the mitral leaflets. • Patient still severly hypotensive but somehow stable emergent mitraclip procedure • main regurgitant jet localized between A1-P1 and A2P2, smaller jet originated more medially • leaflet grasping in the zone of the major regurgitant jet was impossible due to the large flail gap • a more medial grasp was successfully attempted in order to narrow the flail gap first clip positioning emergent mitraclip procedure • the first clip reduced the flail gap enough to narrow the leaflets so that they could be grasped by a second clip second clip emergent mitraclip procedure • The second clip reduced significantly the MR, which nevertheless remained at least moderate emergent mitraclip procedure • 2 clip positioned, good TEE and angiographic result • rapid haemodynamic improvement • procedural time: about 2 hours (skin to skin) • transferred to ICU follow up • weaned from mechanical ventilation after 3 days • weaned from IABP after 5 days • echo: normal LV dimensions, normal EF, moderate residual MR, no evidence of (partial) clip detachment • development of allergic skin reaction to clopidogrel requiring treatment with steroids and switch to prasugrel follow up • after 10 days transferred to normal ward • during following days episodes of arterial hypotension • evidence of progressive MR worsening with preserved ventricular function • MVR planned and carried on after 5 weeks from admission (bioprosthesis) • dischareged 6 days after MVR • asymptomatic at follow up, preserved EF, normal bioprosthesis function thank you!
