Loss of Leaflet Insertion After Percutaneous Mitral Valve Repair Requiring Left Ventricular Assist Device Implantation: Usefulness of 3D Multiplanar Reconstruction

J INVASIVE CARDIOL 2019;31(9):E274-E276.

Key words: 3D-TEE, left ventricular assist device, MitraClip, percutaneous mitral repair, transesophageal echocardiography

A 71-year-old man with ischemic cardiomyopathy (ejection fraction, 20%) and severe functional mitral regurgitation (MR) underwent transcatheter mitral valve repair using MitraClip (Abbott Vascular); four clips were implanted with residual moderate MR. He subsequently became symptomatic for resting dyspnea and dependent on inotropic support. Transesophageal echocardiogram (TEE) showed recurrence of severe MR (Video 1); there was no clip detachment, but a tear of the posterior leaflet along the edge of the central clips was evident, suggesting loss of leaflet insertion (LLI) (Figure 1). As a second MitraClip procedure would have been challenging because of LLI, a left ventricular assist device (LVAD) was implanted and the clips were removed (Video 2). Six month follow-up exam was unremarkable.

Recurrent MR after MitraClip implantation could be due to iatrogenic injury, annular dilation, and/or cardiomyopathy progression, as well as clip detachment and LLI. The latter is characterized by a tear of the leaflet at the insertion in the atrial aspect of the clip. A diagnostic clue is represented by a regurgitant jet parallel to the clip, with the flow convergence area in between the clip and the leaflet tip. Three-dimensional multiplanar reconstruction (3D-MPR) was very useful for this diagnosis (Figure 2).

MR recurrence after MitraClip implantation is challenging; mitral valve surgery is high risk, and repeat MitraClip intervention could be feasible but is technically challenging (especially for risk of stenosis). In addition, when LLI is identified as the mechanism of failure, the chance of repeat procedural success seems low. As shown in this case, LVAD implantation may be a solution to address MitraClip failure.

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From the ¹Echocardiography Unit, ²Cardiac Surgery Unit, and ³Cardiothoracic Intensive Care Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted January 22, 2019.

Address for correspondence: Francesco Melillo, MD, San Raffaele University Hospital, Via Olgettina 60, 20132 Milan, Italy. Email: melillo.francesco@hsr.it