Transcatheter therapies for mitral regurgitation

Rescue transventricular off-pump mitral valve repair with artificial neochords for acute mitral regurgitation due to postinfarction papillary muscle rupture

Background

We report 3 cases of rescue transventricular off-pump mitral valve (MV) repair in high-risk patients with acute mitral regurgitation (MR) due to post–myocardial infarction (MI) papillary muscle rupture (PMR).

Methods

The 3 patients presented with acute inferior ST elevation myocardial infarction, cardiogenic shock, and pulmonary edema. Their preoperative peak troponin I levels were 1909 ng/L, 16,963 ng/L, and 8299 ng/L. All 3 patients underwent successful percutaneous intervention to the culprit coronary artery, and antiplatelet therapy was initiated. All patients required inotropic support and had an intra-aortic balloon pump inserted preoperatively. Transesophageal echocardiography (TEE) demonstrated severe eccentric MR due to the leaflet prolapse secondary to PMR. The patients’ estimated EuroSCORE II scores were 16.03%, 16.68%, and 7.81%, and their Society of Thoracic Surgeons scores were 14.77%, 18.24%, and 9.8%, respectively. All 3 patients underwent urgent transventricular off-pump MV repair using artificial chords, with 2 or 3 three neochords implanted. The duration of operation was <2 hours, and intraoperative and postoperative drainage was minimal in all cases. MV function was assessed by qualitative and semiquantitative TEE.

Results

Intraoperative MR reduction to a mild level was achieved in all 3 patients. All patients had moderate MR at discharge, likely due to left ventricular remodeling. Severe MR recurred in all patients, at 5, 4, and 2 months of follow-up, respectively. All 3 patients underwent an elective MV reoperation via conventional approach.

Conclusions

Off-pump transventricular MV repair may offer a safe and feasible alternative to stabilize high-risk patients with acute MR due to post-MI PMR. Although early MR recurrence is concerning, urgent transventricular MV repair may serve as a bridge to conventional surgery in such unstable patients.

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Percutaneous edge-to-edge repair in high-risk and elderly patients with degenerative mitral regurgitation: midterm outcomes in a single-center experience

OBJECTIVE

The study objective was to report the midterm outcomes of MitraClip implantation in inoperable or high-risk surgical candidates with degenerative mitral regurgitation.

METHODS

From October 2008, data of all high-risk or elderly patients with severe degenerative mitral regurgitation who underwent MitraClip implantation were prospectively collected.

RESULTS

Forty-eight high-risk consecutive patients with severe degenerative mitral regurgitation underwent MitraClip implantation (mean age, 78.5 ± 10.8 years; 56.6% of the patients were aged ≥ 80 years). Mean Society of Thoracic Surgeons score was 12% ± 10%, and 71% were in New York Heart Association class III or IV. Mean left ventricular ejection fraction was 57% ± 11%. The device was successfully implanted in 47 of 48 patients (98%). In-hospital mortality was 2%. The median intensive care unit stay was 22 hours; patients were discharged from the hospital in an average of 4.5 ± 2.4 days. Predischarge echocardiography showed a mitral regurgitation reduction to grade 2+ or less in 43 of 47 patients (91.5%). Actuarial survival was 89% ± 5.2% and 70.2% ± 9% at 1 and 2 years, respectively (82% ± 9% in patients aged <80 years and 95% ± 4.4% in patients aged ≥ 80 years at 1 year; P = .9). Freedom from mitral regurgitation 3+ or greater was 80% ± 7% at 1 year and 76.6% ± 7% at 2 years. At 1 year, 93% of survivors were in New York Heart Association class I or II (100% of patients aged <80 years and 88% of patients aged ≥ 80 years; P = .4). Significant quality of life improvements were documented. A significant improvement in 6-minute walk test performance was observed.

CONCLUSIONS

MitraClip therapy is a valuable alternative to surgery in high-risk and elderly patients with degenerative mitral regurgitation. Clinical benefits also are obtained in octogenarians.