Abstract
Objectives
The objective of this study was to describe a transcatheter edge-to-edge repair procedure for severe mitral regurgitation (MR) in a patient with complex anatomy because of prior surgical ring implantation and posterior dehiscence.
Key Steps
The key steps are as follows: 1) preprocedural transesophageal echocardiography (TEE) identified wide posterior ring dehiscence with severe MR; 2) the detached surgical ring was located at the coaptation plane, complicating access; 3) the delivery system was navigated outside the ring to avoid interference; 4) a small clip was used to facilitate crossing, followed by sequential implantation of 2 NTW clips to reduce MR; and 5) final TEE confirmed mild residual MR and acceptable transmitral gradient.
Potential Pitfalls
The potential pitfalls included the following: 1) difficult access because of altered mitral geometry and ring displacement; 2) risk of device malposition or interaction with the surgical ring; and 3) precise imaging guidance and clip selection are essential to success.
Take-Home Message
Transcatheter edge-to-edge repair can be safely and effectively performed in anatomically complex postsurgical settings when standard approaches are not feasible.
Key words: chronic heart failure, echocardiography, mitral valve, valve repair
Graphical Abstract
Transcatheter edge-to-edge repair (TEER) is increasingly used in the treatment of mitral regurgitation (MR) across diverse anatomic scenarios. Surgical mitral ring dehiscence represents a complex situation where percutaneous approaches must be carefully planned. This case highlights the feasibility of TEER even in such challenging anatomy.
Take-Home Message
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TEER can be safely and effectively performed in anatomically complex postsurgical settings when standard approaches are not feasible.
Case Presentation
A 79-year-old man with prior surgical mitral valve repair using a 32-mm Edwards ring was admitted for worsening heart failure (NYHA functional class III/IV). Transesophageal echocardiography (TEE) revealed wide dehiscence of the mitral ring from the anterolateral to the posteroseptal commissure, with severe MR secondary to posterior leaflet restriction (Figure 1, Video 1).
Figure 1.
Preprocedural Transesophageal Echocardiogram
(A) Three-dimensional transesophageal echocardiography reconstruction of the MV showing posterior dehiscence of the surgical ring (red asterisk), creating an ample orifice between the surgical ring and the mitral annulus. The detached surgical ring (red asterisk) and dehiscence are shown in the 2-chamber view (B) and the long-axis view (C). Massive mitral regurgitation is demonstrated in a 3-dimensional color Doppler reconstruction (D) and with color Doppler imaging in the 2-chamber (E) and long-axis (F) views. LA = left atrium; LV = left ventricle; MV = mitral valve; Surgical ring = ring.
The heart team deemed the patient high surgical risk. TEER was selected, using initial navigation outside the surgical ring. A small clip device was used first to facilitate access, followed by sequential implantation of 2 wide clip devices to optimize MR reduction (Figure 2).
Figure 2.
Transcatheter Edge-to-Edge Repair Procedure
The CDS crosses outside of the surgical ring into the LV as seen in the 3-dimensional transesophageal echocardiography reconstruction (A), 2-chamber view (B), and long-axis view (C). CDS = clip delivery system; LA = left atrium; LV = left ventricle; MV = mitral valve; SR = surgical ring.
Postprocedural TEE confirmed mild residual MR with a mean gradient of 5 mm Hg (Figure 3, Video 2). The patient experienced marked clinical improvement and has remained free of heart failure hospitalization during follow-up.
Figure 3.
Final Result of the Procedure
A significant reduction of mitral regurgitation (MR) is observed after deployment of 2 NTW clip devices, visualized in the 3-dimensional transesophageal echocardiography reconstruction (A), 2-chamber view (B), and long-axis view (C). Mild residual MR remains, and the transmitral gradient is within acceptable limits. Clip = deployed clips; LV = left ventricle; MV = mitral valve; SR = surgical ring.
Discussion
Surgical ring dehiscence presents technical challenges for percutaneous repair. In this case, careful procedural planning, imaging guidance, and selection of appropriate clip sizes were key for success. Navigating outside the ring and the use of multiple clip devices helped achieve optimal mitral competence.
Conclusions
TEER provides a viable and safe alternative to surgery even in complex postsurgical scenarios. Expansion of operator skills and procedural techniques can extend the applicability of percutaneous therapies to anatomies beyond standard indications.
Visual Summary.
Timeline of the Case
| Timeline | Events |
|---|---|
| Admission day 1 | A 79-y-old man presented with NYHA functional class III-IV symptoms and decompensated heart failure. Past history of surgical mitral ring implantation for severe ischemic functional MR. |
| Admission day 2 | Initial transthoracic echocardiography suggested severe MR. Transesophageal echocardiography confirmed wide dehiscence of the surgical mitral ring with massive functional MR because of restricted posterior leaflet motion. |
| Admission day 3 | Multidisciplinary heart team discussion deemed the patient high risk for redo mitral surgery. Decision was made to proceed with TEER using a clip-based device. |
| Admission day 7 | TEER procedure was performed successfully. The clip delivery system was navigated outside of the dehisced surgical ring. Sequential deployment of 2 wide clip devices (NTW) achieved significant MR reduction with a mean transmitral gradient of 5 mm Hg. |
| Admission day 8 | Patient showed significant clinical improvement postprocedure. No recurrence of heart failure symptoms was observed. Discharged home in stable condition. |
| Outpatient follow-up (day 30 postadmission) | Follow-up at 30 d showed patient improved to NYHA functional class I with no limiting symptoms and echo showed trivial MR. |
MR = mitral regurgitation; TEER = transcatheter edge-to-edge repair.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
For supplemental videos, please see the online version of this paper.
Contributor Information
María Salgado Barquinero, Email: msalgadobarq@gmail.com.
Marcel Almendárez Lacayo, Email: marcel.almendarez@gmail.com.
Andrea Aparicio Gavilanes, Email: apariciogavilanes@gmail.com.
Appendix
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Transesophageal echocardiogram showing severe mitral regurgitation (MR) because of posterior leaflet retraction, with pseudoprolapse of the anterior leaflet. A very eccentric MR jet is directed toward the posterior wall of the left atrium.
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Comparative transesophageal echocardiography displaying identical imaging planes before and after the percutaneous mitral repair. A significant reduction in mitral regurgitation is achieved without significant residual transmitral gradient.
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
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Transesophageal echocardiogram showing severe mitral regurgitation (MR) because of posterior leaflet retraction, with pseudoprolapse of the anterior leaflet. A very eccentric MR jet is directed toward the posterior wall of the left atrium.
◼
Comparative transesophageal echocardiography displaying identical imaging planes before and after the percutaneous mitral repair. A significant reduction in mitral regurgitation is achieved without significant residual transmitral gradient.