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infarction. In cases of TCM with VSP, once hemodynamic instability occurs, an emergency rescue operation will be mandatory. REFERENCES 1. Dote K, Sato H, Tateishi H, et al: Myocardial stunning due to simultaneous multivessel coronary spasm: A review of 5 cases. J Cardiol 1991;21:203–214. 2. Akashi YJ, Goldstein DS, Barbaro G, et al: Takotsubo cardiomyopathy: A new form of acute, reversible heart failure. Circulation 2008;118:2754–2762. 3. Birnbaum Y, Fishbein MC, Blanche C, et al: Ventricular septal rupture after acute myocardial infarction. N Engl J Med 2002;347:1426–1432. 4. Wittstein IS, Thiemann DR, Lima JA, et al: Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–548. 5. Prasad A, Lerman A, Rihal CS: Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction. Am Heart J 2008;155:408–417. 6. Sadamatsu K, Tashiro H, Maehira N, et al: Coronary microvascular abnormality in the reversible systolic dysfunction observed after noncardiac disease. Jpn Circ J 2000;64:789–792. 7. Tsuchihashi K, Ueshima K, Uchida T, et al: Angina pectoris-myocardial infarction investigations in Japan. Transient left ventricular apical ballooning without coronary artery stenosis: A novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 2001;38: 11–18. 8. Sakai K, Ochiai H, Katayama N, et al: Ventricular septal perforation in a patient with takotsubo cardiomyopathy. Circ J 2005;69:365–367. 9. Izumi K, Tada S, Yamada T: A case of takotsubo cardiomyopathy complicated by ventricular septal perforation. Circ J 2008;72:1540–1543. 10. Mariscalco G, Cattaneo P, Rossi A, et al: Tako-tsubo cardiomyopathy complicated by ventricular septal perforation and septal dissection. Heart Vessels 2010;25:73–75. 11. Aikawa T, Sakakibara M, Takahashi M, et al: Critical takotsubo cardiomyopathy complicated by ventricular septal perforation. Intern Med 2015;54:37–41. 12. Ohara Y, Hiasa Y, Hosokawa S, et al: Left ventricular free wall rupture in transient left ventricular apical ballooning. Circ J 2005;69:621–623.
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Development of a Severe Mitral Valve Stenosis Secondary to the Treatment of Mitral Regurgitation with a Single MitraClip Anja Osswald, M.D.,* Odeaa Al Jabbari, M.D.,y Walid K. Abu Saleh, M.D.,y Colin Barker, M.D.,y Arjang Ruhparwar, M.D.,* Christof Karmonik, Ph.D.,z and Matthias Loebe, M.D., Ph.D.* *Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany; yMethodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas; and zDepartment of Translational Imaging, Houston Methodist Research Institute, Houston, Texas ABSTRACT We report a patient with class III heart failure symptoms due to mitral regurgitation (MR) subsequent to nonischemic cardiomyopathy. The patient underwent percutaneous transcatheter mitral valve repair using a single MitraClip, which reduced the MR; however it created mildto-moderate mitral stenosis, which progressed to severe mitral stenosis. Subsequently the patient underwent mitral valve replacement surgery.
doi: 10.1111/jocs.12692 (J Card Surg 2016;31: 153–155)
Percutaneous transcatheter mitral valve repair using the MitraClip system has become an effective alternative treatment for patients with severe or moderate-to-severe mitral regurgitation (MR) who are high risk for a conventional surgical intervention.1 Studies have evaluated the safety and feasibility of the MitraClip and reported good outcomes with few complications.2 This report focuses on a patient who presented with severe mitral stenosis after treatment of MR with a single MitraClip.
Conflict of interest: The authors acknowledge no conflict of interest in the submission. Disclaimers: None. Funding: None. Address for correspondence: Odeaa Al jabbari, M.D., Houston Methodist Hospital, 6550 Fannin St. Houston, TX 77030. Fax: 713790-2859; e-mail:
[email protected]
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CASE PRESENTATION A 55-year old Caucasian female presented with NYHA class III symptoms, shortness of breath on exertion, and fatigue. Her past medical history included nonischemic cardiomyopathy first diagnosed in 1994, chronic kidney disease stage 3, hypertension, diabetes type II, dyslipidemia, morbid obesity, obstructive sleep apnea, and implantation of a cardiac resynchronization therapy device (CRT). Echocardiographic studies confirmed severe (grade 4þ) MR subsequent to nonischemic cardiomyopathy with a left ventricular ejection fraction (EF) of 20–25%, a mitral valve area (MVA) of 4.1 cm2, and left ventricular end systolic dimension (LVESD) of 48 mm. Echo also showed no calcium within the mitral valve leaflets. Estimated pulmonary artery systolic pressure (PASP) was 53 mmHg. Since she had already received maximal medical therapy, she was enrolled in the COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for heart failure patients with functional mitral regurgitation) and randomized to percutaneous transcatheter mitral valve repair using the Abbott’s MitraClip1 System (Campbell Avenue, Menlo Park, CA, USA).3 During implantation the left atrium was approached via trans-septal puncture, then the MitraClip was introduced into the left atrium. The first
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two clipping attempts appeared to be too medial because they reduced the MR but created significant mitral valve stenosis. Repositioning the clip further laterally and clipping the A2 and P2 mitral valve leaflets together led to a satisfactory result, reducing the severe MR to mild and creating a mild-to-moderate stenosis. Intraoperative echocardiography confirmed successful insertion of the MitraClip. The estimated EF went up to 40–44%. The mean mitral valve gradient increased from 3 to 7 mmHg; MVA was 1.4 cm2. The patient recovered well and was discharged home two days postprocedure with no reported complications. Although there were signs of a mild mitral valve stenosis in the transesophageal echocardiography (TEE) postprocedure, in the one-month follow up there were no problems concerning the MitraClip. However, three months after MitraClip insertion the patient was admitted due to worsening heart failure. There were no abnormalities with the MitraClip on echocardiography. However, the MV gradient was 19 mmHg. With diuretic therapy the symptoms improved and the patient was discharged. However, one month later she presented with NYHA class III symptoms. She reported shortness of breath, dyspnea on exertion, fatigue, syncope, orthopnea, and swollen extremities for the last two weeks. The echo showed severe mitral stenosis, with an EF of 35–39% and an estimated mean mitral valve gradient now of 16 mmHg (Fig. 1). In view of her worsening symptoms, her case was reevaluated. LVAD implantation was discussed, but it was decided to replace the mitral valve with a biological valve. During the surgery the mitral valve and clip were resected (Fig. 2A and B) and sent to pathology which showed no calcification of the valve. A 29 mm Epic St. Jude bioprosthetic porcine valve (St. Jude Medical1 TrifectaTM Valve, St. Paul, MN, USA) was implanted. The subvalvular apparatus was preserved. The patient did well after surgery and was discharged home without any complications. This was done under an institutional review board (IRB) approved protocol and the patient gave full consent.
DISCUSSION Figure 1. Preoperative echocardiography showing focal echodensity on the tips of the mitral valve leaflets consistent with mitral valve clip device (red arrow).
The four-year results in the EVEREST II study contained one patient out of 184 who developed a
Figure 2. Mitral valve with MitraClip in situ (A) and after resection (B).
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mitral valve stenosis with an MVA of 1.5 cm2 and a mean MV gradient of 14.5 mmHg.1 To our knowledge there are only two additional patients with MR who developed a mitral stenosis after MitraClip insertion.4,5 One patient had end-stage renal failure, pulmonary hypertension, and cardiomyopathy and developed severe mitral stenosis 16 months after the insertion of two MitraClips.4 The placement of two MitraClips might be a predisposing factor. A second patient with severe mitral and tricuspid regurgitation and prior aortic valve replacement presented with severe mitral stenosis three months postprocedure with significant turbulence across the MV orifice and an elevated peak and mean gradient. Possible reasons include the borderline MV orifice of 3.9 cm2 and the heavily calcified annulus of the MV.5 In our case, a mild-to-moderate mitral stenosis was created when placing the MitraClip. Although the oneand three-month postprocedure echocardiography indicated no complications concerning the clip, it resulted in the development of the severe mitral stenosis. Another possible reason is an extensive reaction and inflammation of the mitral leaflets. Active inflammatory processes with accumulation of macrophages and T-lymphocytes often occur in degenerative valve stenosis.5 Additionally, there was a mild calcification of the mitral leaflets and a thickened or calcified mitral annulus, which could also be a predisposing factor. The clip itself could have functioned as a mechanical stressor and caused the additional local calcification reported by the pathologist. The patient also has chronic kidney disease stage 3, which often accelerates calcification. It is possible that the use of the MitraClip in patients with calcified valves and annuli, and those
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who have systematic inflammatory diseases such as chronic renal dysfunction, may contribute to the development of mitral stenosis.
CONCLUSION Development of mitral valve stenosis is a potential complication of MR treatment with the MitraClip. Stenosis may be due to extensive leaflet reaction and inflammation. Conventional valve replacement is possible in patients developing severe stenosis after percutaneous transcatheter mitral valve repair with the MitraClip system. REFERENCES 1. Mauri L, Foster E, Glower DD, et al: Four-year results of a randomized controlled trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol 2013;62(4):317–328. 2. Feldman T, Kar S, Rinaldi M, et al: Everest investigators. Percutaneous mitral repair with the MitraClip system: Safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol 2009;54(8):686–694. 3. Young A, Feldman T: Percutaneous mitral valve repair. Curr Cardiol Rep 2014;16(1):443. 4. Singh K, Raphael J, Colquhoun D: A rare case of mitral stenosis after MitraClip placement: Transesophageal echocardiography findings and examination. Anesth Analg 2013;117(4):777–779; discussion 779. 5. Cockburn J, Fragkou P, Hildick-Smith D: Development of mitral stenosis after single MitraClip insertion for severe mitral regurgitation. Catheter Cardiovasc Interv 2014;83(2):297–302.
