CARDIOVASCULAR SURGERY

KNOW PRO

ARTICLE – MITRACLIPS

BY:

ANDREA VALENTINA VILLAMIZAR BLANCO

FOR:

LIDY JANNETH HIGUERA IBAÑEZ

 Mitral valve repair with the MitraClip® device in a patient with acute mitral regurgitation after
myocardial infarction.

The case of a 76-year-old man who came to our center due to anginal chest pain that started in
the previous 24 hours is presented. The electrocardiogram at that time showed waves of necrosis
located inferolaterally with ST elevation in these leads. Urgent coronary angiography was
performed, which demonstrated occlusion of the proximal circumflex artery and non-significant
irregularities in the rest of the arteries. In this situation, it was decided to treat the artery causing
the infarction. An 8 3/23mm Multilink stent (Abbott Vascular; Santa Clara, California, United
States) was implanted, with optimal angiographic results. In the subsequent 24 hours, the patient
suffered two episodes of acute pulmonary edema that were controlled with diuretic and
vasodilator treatment, without the need for amines or balloon pump. Subsequently, the patient
maintained signs of residual pulmonary congestion. A transthoracic echocardiogram at this time
showed severe mitral regurgitation (MR) due to restriction of the posterior leaflet related to
ischemic involvement of the posteromedial papillary muscle. 12 hours after this event, the patient
suffered an acute stroke in the territory of the left middle cerebral artery, from which he
recovered ad integrum in hours. With a view to correcting the valve disease, the case was
presented to the surgeons, who dismissed the intervention due to its high risk (Society of Thoracic
Surgeons [STS] score: mortality, 6.7%; logistic EuroScore, 29.1%). Given the improbable good
evolution of the patient without correcting the valvular complication, mitral repair was decided
using the MitraClip® device (Abbott Vascular). Transesophageal echocardiography was previously
performed, which revealed severe MR with regurgitant jet located in segments A2-P2, although
with a certain medial component (A3-P3).

The procedure was performed under general anesthesia and guided by transesophageal
echocardiography. After grasping both leaflets in position A2-P2, a significant decrease in
regurgitation was found, although moderate residual MR persisted in the area lateral to the
implanted clip. For this reason, a second clip was implanted lateral to the previous one, which
managed to reduce the MR to <1/4.

Acute MI in the context of an ST-elevation infarction due to papillary muscle dysfunction is

considered a mechanical complication that usually causes clinical deterioration in patients, leading
to pulmonary edema and, occasionally, cardiogenic shock. In this scenario, mitral valve surgery is
considered the treatment of choice. However, this surgery is associated with high mortality1 in
relation to the high-risk profile of the patients, which is why surgical teams sometimes reject
them. It is in this context that transcatheter valve treatment techniques are gaining importance. In
the mitral valve, the MitraClip® is the only device that has gained wide clinical use, mainly in
Europe. Recent studies show that the use of this device is safe and effective, and achieves an
improvement in functional class in 80% of cases and a persistent reduction in MR after one year2–
4. However, information on the treatment of patients with acute MI is scarce5. Given that this is a
phenomenon of recent appearance and of functional etiology, the leaflets present characteristics
of amount of tissue and coaptation surface that are usually ideal for clip implantation. MR
correction leads to rapid clinical recovery, by effectively correcting volumetric overload; however,
there are still few data on the effect of the clip on ventricular remodeling after infarction, so more
studies with appropriate image follow-up are needed to determine it.

Taken from: https://www.revespcardiol.org/es-reparacion-valvular-mitral-con-dispositivo-articulo-

S0300893214006101

QUESTIONS

1) What was the diagnostic method prior to surgery?

a. T A C

b. transesophageal echocardiography

c. angiography

2) In MI in the context of an ST elevation infarction, what is the dysfunctional muscle?

a. Papillary

b. trabecular

c. triceps

3) What percentage represents the improvement with the use of mitraclips?

a. fifty%

b. 70%

c. 80%