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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 22  |  Issue : 3  |  Page : 212-213  

Transcatheter mitral valve repair using mitraclip in secondary mitral valve regurgitation guided by real-time pressure–volume loops


1 Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
2 Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, FL, USA
3 Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA

Date of Submission17-Aug-2020
Date of Acceptance29-Aug-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Abdallah El Sabbagh
Mayo Clinic, 4500 San Pablo Road South, Jacksonville FL 32224
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_145_20

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   Abstract 


Worsening of left ventricular (LV) function is a potential complication after repair of secondary mitral valve regurgitation, and one which has limited methods for predicting its risk of occurrence. We present a case utilizing real-time pressure–volume loops intraprocedurally to monitor hemodynamic changes before and after application of a trancatheter MitraClip device in a patient with severe symptomatic secondary mitral regurgitation (MR). Worsening of LV function is a potential complication after repair of secondary mitral valve regurgitation. We present a case utilizing real-time pressure–volume loops intraprocedurally to monitor hemodynamic changes before and after application of a transcatheter MitraClip device in a patient with severe symptomatic secondary MR.

Keywords: Invasive hemodynamic monitoring, MitraClip, pressure–volume loops


How to cite this article:
Espinosa S, El Sabbagh A, Behfar A, Patel P. Transcatheter mitral valve repair using mitraclip in secondary mitral valve regurgitation guided by real-time pressure–volume loops. Heart Views 2021;22:212-3

How to cite this URL:
Espinosa S, El Sabbagh A, Behfar A, Patel P. Transcatheter mitral valve repair using mitraclip in secondary mitral valve regurgitation guided by real-time pressure–volume loops. Heart Views [serial online] 2021 [cited 2021 Nov 28];22:212-3. Available from: https://www.heartviews.org/text.asp?2021/22/3/212/328018




   Introduction Top


Deterioration of left ventricular (LV) function after mitral valve repair (MVr) can occur despite successful elimination of mitral regurgitation (MR), and currently, there are no standardized methods for predicting this decline.[1],[2] We present a case using real-time pressure–volume loops to assess changes in postoperative LV function after transcatheter MVr.


   Case Presentation Top


A 72-year-old gentleman with a history of coronary artery bypass, ischemic cardiomyopathy (LV ejection fraction [LVEF] – 30%), LV end-systolic diameter – 62 mm, and severe symptomatic secondary MR presented for transcatheter MVr using MitraClip device (Abbott Vascular Structural Heart, Menlo Park, CA).

Given the concerns for postoperative worsening of LV function after MitraClip in the setting of a diminished baseline cardiac reserve, the decision was made to utilize pressure-volume (PV) loop monitoring to provide real-time intraprocedural LV hemodynamic monitoring.

A 7-French 10 mm PV loop pigtail catheter (CD Leycom, Zoetermeer, The Netherlands) was inserted in a retrograde fashion into the LV apex through a 7-French femoral arterial access [Figure 1]. The catheter was then connected to a pulmonary venous flow (PV) signal processor (Inca, CD Leycom). Volume calibration was done using LV stroke volume obtained from transesophageal echocardiography. Real-time continuous PV loops were measured and recorded at baseline and postgrasping of the A2-P2 segment of the mitral valve using a MitraClip XTR device. PV loops revealed that the overall effect of leaflet grasping was an increase in stroke volume compared to baseline, providing reassurance for clip release [Figure 2]. The patient was discharged home the next day and reported significant improvement in dyspnea at 30-day follow-up.
Figure 1: Procedural set up for real-time pressure–volume (PV) loop hemodynamic monitoring during MitraClip placement

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Figure 2: Averaged and merged left ventricular pressure–volume (PV) loops at baseline (blue line) and after leaflet grasping using MitraClip XTR (orange line), showing an increase in stroke volume after leaflet grasping

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   Discussion Top


LV function after MVr can worsen despite successful elimination of MR, both in patients with normal and abnormal preoperative LVEF.[1],[2] This decline in LV function is likely due to the acute changes in afterload with the removal of the low-impedance regurgitant systolic flow despite decreased (end diastolic) wall stress and reduction in preload.[1]

This is particularly concerning in secondary MR where LV dysfunction is present at baseline, and the hemodynamic response to MVr is harder to predict compared to primary MR. At present, there are no standard methods to predict postoperative worsening of LV function after percutaneous edge-to-edge repair in patients with severe LV dysfunction, although elevated LV end-systolic dimension and RV systolic pressures measured on echocardiogram have been proposed as risk factors.[2]


   Conclusion Top


This novel application of PV loops during MitraClip can provide real-time hemodynamic guidance in patients with severe MR at risk of postoperative worsening of LV function.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Gaemperli O, Biaggi P, Gugelmann R, Osranek M, Schreuder JJ, Bühler I, et al. Real-time left ventricular pressure-volume loops during percutaneous mitral valve repair with the MitraClip system. Circulation 2013;127:1018-27.  Back to cited text no. 1
    
2.
Quintana E, Suri RM, Thalji NM, Daly RC, Dearani JA, Burkhart HM, et al. Left ventricular dysfunction after mitral valve repair--The fallacy of "normal" preoperative myocardial function. J Thorac Cardiovasc Surg 2014;148:2752-60.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]



 

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