Calcium Is Not an Issue for Transcatheter Therapy in the Mitral Valve: The Role of Independent Leaflet Grasping

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00213. Epub July 30, 2024.

A 75-year-old woman with a history of heart failure was referred for dyspnea upon exertion due to severe mitral regurgitation (MR). Transoesophageal echocardiography showed severe MR, which was attributed to the tethering of the posterior leaflet (scallop P2) due to the presence of mild posterior mitral annular calcification (MAC). The following mid-segment (A2) of anterior leaflet prolapse resulted in a small coaptation defect (Figure A). After Heart Team discussion, a MitraClip NTW (Abbott) procedure was planned. However, the presence of MAC, eccentric MR, and short posterior leaflet suggested unfavorable outcomes.¹  

We made multiple attempts to simultaneously grasp both leaflets but were unsuccessful due to the short grasp length of the posterior leaflet (9 mm) (Figure B). Thus, we decided to grasp each leaflet individually and were initially able to grasp the more mobile anterior leaflet, however, capture of the posterior leaflet was still not feasible.

It was then decided to attempt to initially grasp the calcified posterior leaflet, despite the risk for its rupture due to stretching by the clip. The clip arms were opened at an angle of almost 160° and we were able to grasp the posterior leaflet (Figure C, Video 1); next, the anterior leaflet was successfully grasped (Figure D, Video 2). After clip placement, significant MR reduction with 2 distinct jets was detected (Figure E, Video 3), while 3-dimensional echocardiography showed a double-orifice mitral valve (Figure F, Video 4). After 3 months, the patient was asymptomatic with mild MR.

Affiliations and Disclosures

Kyriakos Dimitriadis, MD, PhD; Eirini Beneki, MD, MSc, PhD; Konstantinos Aznaouridis, MD, PhD; Constantina Aggeli, MD, PhD; Konstantinos Tsioufis, MD, PhD

From the First Cardiology Department, School of Medicine, Hippokration General Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and to the publication thereof.

Address for correspondence: Kyriakos Dimitriadis, MD, PhD, Vasilissis Sofias 114, Athens, GR 11528. Email: dimitriadiskyr@yahoo.gr

Reference

1. Fernández-Peregrina E, Pascual I, Freixa X, et al. Transcatheter edge-to-edge mitral valve repair in patients with mitral annulus calcification. EuroIntervention. 2022;17(16):1300-1309. doi: 10.4244/EIJ-D-21-00205