title: Percutaneous direct mitral annuloplasty using the Mitralign Bident system: description of the method and a case report.
abstract: BACKGROUND
  Functional mitral regurgitation (FMR) is known to contribute to a poor prognosis in patients with heart failure (HF). Current guidelines do not recommend cardiac surgery in patients with FMR and impaired ejection fraction due to the high procedural risk. Percutaneous techniques aimed at mitral valve repair may constitute an alternative to currently used routine medical treatment.
  
  
  OBJECTIVE
  To provide a description of a novel percutaneous suture-based technique of direct mitral annuloplasty using the Mitralign Bident system, as well as report our first case successfully treated with this method.
  
  
  METHODS
  A deflectable guiding catheter is advanced via the femoral route across the aortic valve to the posterior wall of the ventricle. A nested deflectable catheter is advanced through the guide toward the mitral annulus that allows the advancement of an insulated radiofrequency wire to cross the annulus. The wire is directed across the annulus in a target area that is 2-5 mm from the base of the leaflet into the annulus, as assessed by real-time 3D transoesophageal echocardiography. After placement of the first wire, another wire is positioned using a duel lumen bident delivery catheter, which provides a predetermined separation between wires (i.e. 14, 17 or 21 mm). Each wire provides a guide rail for implantation of sutured pledget implants within the annulus. Two pairs of pledgets are implanted, one pair in each of the P1 and P3 scallop regions of the posterior mitral annulus. A dedicated plication lock device is used to provide a means for plication of the annulus within each pair of the pledgets, and to retain the plication by delivering a suture locking implant. The plications result in improved leaflet coaptation and a reduction of the regurgitant orifice area.
  
  
  RESULTS
  A 60-year-old female with diagnosed dilated cardiomyopathy, concomitant FMR class III and congestive HF was successfully treated with the Mitralign Bident system. Two pairs of pledgets were implanted resulting in an improvement of transoesophageal echocardiographic parameters, including proximal isovelocity surface area radius (0.7 cm to 0.4 cm), effective regurgitant orfice area (0.3 cm² to 0.1 cm²) and mitral regurgitant volume (49 mL to 10 mL).
  
  
  CONCLUSIONS
  Percutaneous mitral annuloplasty with the Mitralign Bident system is feasible. Future clinical trials are needed to assess its safety and efficacy.
authors.affiliation: HCP Medical Centre, Poznan University of Medical Sciences, Poznan, Poland. tomasz.siminiak@usoms.poznan.pl.
authors.forename: Tomasz
authors.initials: T
authors.lastname: Siminiak
authors.forename: Rafał
authors.initials: R
authors.lastname: Dankowski
authors.forename: Artur
authors.initials: A
authors.lastname: Baszko
authors.forename: Christopher
authors.initials: C
authors.lastname: Lee
authors.forename: Ludwik
authors.initials: L
authors.lastname: Firek
authors.forename: Piotr
authors.initials: P
authors.lastname: Kałmucki
authors.forename: Andrzej
authors.initials: A
authors.lastname: Szyszka
authors.forename: Adam
authors.initials: A
authors.lastname: Groothuis
mesh_terms: D002311:Cardiomyopathy, Dilated / Q000150:complications; D017548:Echocardiography, Transesophageal; D005240:Feasibility Studies; D005260:Female; D006333:Heart Failure / Q000150:complications; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000379:methods*; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D062645:Percutaneous Coronary Intervention / Q000379:methods*; D016896:Treatment Outcome