Which is the Best Option in Calcified Leaflets? MitraClip NTR or XTR?

J INVASIVE CARDIOL 2020;32(10):E265. 

Key words: calcified leaflet, MitraClip implantation, mitral regurgitation

An 89-year-old man presented with dyspnea (New York Heart Association class IV). He had undergone coronary artery bypass graft and surgical aortic valve replacement. Transesophageal echocardiography (TEE) revealed severe mitral regurgitation (MR) with flail anterior leaflet, calcified posterior leaflet (Figures 1A-1D; Videos 1 and 2) and high left atrium pressure (LAP) (Figure 1E). Transcatheter edge-to-edge repair using the MitraClip (Abbott Vascular) was performed. Considering the calcified posterior leaflet, we chose NTR to avoid the leaflet damage. However, there was still moderate MR after we grasped the A2/P2 segments using one NTR clip (Figures 1F and 1G) with significant LAP improvement (Figure 1H; Video 3). We decided to retrieve the NTR and implanted an XTR clip in the same position. We then achieved better MR reduction without any leaflet damage (Figure 1I and 1J; Video 4) and further reduction of LAP (Figure 1K). 

The MitraClip XTR has longer clip arms than the NTR; thus, it effectively grasps more leaflet tissue. The XTR clip has a potential risk of leaflet damage when grasping calcified leaflets; therefore, the XTR is considered unsuitable in this situation. As we demonstrated, the XTR clip can achieve a better outcome than the NTR clip even in the case of calcified leaflet. Now, we have the MitraClip G4, which offers an expanded range of clip sizes. Even in the current era of transcatheter edge-to-edge repair, deciding clip size in each case is still a challenge.

View the Supplemental Video Series Here

From ¹the University Heart Center Zurich, Zurich, Switzerland; and ²MacKay Memorial Hospital, Taipei, Taiwan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Taramasso reports consultant income from Abbott Vascular, Boston Scientific, 4tech, and CoreMedic; speaker honoraria from Edwards Lifesciences. Dr Miura reports consultant income from Japan Lifeline. Dr Maisano reports consultant income from Abbott Vascular, Medtronic, Edwards Lifesciences, Perifect, Xeltis, Transseptal Solutions, Cardiovalve, Magenta; grant support from Abbott Vascular, Medtronic, Edwards Lifesciences, Biotronik, Boston Scientific Corporation; royalties from Edwards Lifesciences, 4 Tech, Transseptal solutions, Perifect, and Cardiovalve. Dr Lin reports 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 7, 2020.

Address for correspondence: Shu-I Lin, MD, University Heart Center Zurich, University Hospital of Zurich, Rämistrasse 100, CH-8091, Zürich, Switzerland. Email: yardbird881@gmail.com