title: Multi-MitraClip therapy for severe degenerative mitral regurgitation: "anchor" technique for extremely flail segments.
abstract: In high-risk or inoperable patients, implantation of MitraClip for treatment of severe symptomatic mitral regurgitation (MR) from central (A2/P2 pathology, EVEREST patient) is effective in reducing symptoms and improving functional class. Extending the use of MitraClip to the non-EVEREST patient is of considerable interest. MitraClip implantation for wide flail segments and non-central MR is technically more challenging but represents an important and highly prevalent subset of patients. We present a case of an 82-year-old male referred to our institution for medically refractory primary MR. Trans-esophageal echocardiogram demonstrated severe (4+) MR, annular dilatation, P3 > P2 mitral valve prolapse, malcoaptation, and wide flail gaps and widths. The patient's age, frailty, chronic kidney disease, and mild cognitive impairment rendered him a candidate for MitraClip therapy. Our target area, the areas of maximum flail (A3/P3), proved too wide for grasping. Hence, the first clip was deployed medial to the target area. Subsequent deployment, in a sequential fashion ("zipper technique"), was not technically feasible due to persistent instability of the target area. Consideration was given to an alternative approach by "anchoring" our target area where the 2nd and 3rd clips were deployed lateral to the A3/P3 segment in efforts to "anchor" the maximum flail segment. This maneuver allowed final clip deployment into a more stable target area. Subsequent imaging demonstrated reduction in MR from 4+ to 1+ with preservation of a normal transmitral gradient. We report the first successful US case of four MitraClip implantation for the treatment of severe primary MR by "anchoring" flail segments.
authors.affiliation: Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California.
authors.forename: Gagan D
authors.initials: GD
authors.lastname: Singh
authors.affiliation: Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California.
authors.forename: Thomas W
authors.initials: TW
authors.lastname: Smith
authors.affiliation: Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California.
authors.forename: Jason H
authors.initials: JH
authors.lastname: Rogers
mesh_terms: D000369:Aged, 80 and over; D006328:Cardiac Catheterization / Q000295:instrumentation*; D015897:Comorbidity; D018618:Echocardiography, Doppler, Color; D018619:Echocardiography, Doppler, Pulsed; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology*; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D008945:Mitral Valve Prolapse / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome
keywords: cardiomyopathy; mitral valve disease; percutaneous intervention