Emergent Percutaneous Mitral Valve Repair in Cardiogenic Shock

Author(s): 

Mustafa Ahmed, MD, Director, Structural Heart Disease Program, Princeton Baptist Medical Center, Birmingham, Alabama

Note: Read CLD's accompanying interview with Dr. Ahmed at: Emergent Percutaneous Mitral Valve Repair in Cardiogenic Shock: Talking With the Operator

Accompanying videos:

All videos located on CLD's multimedia page: http://www.cathlabdigest.com/multimedia

Video 1. ECMO cannula in the right atrium with the ProTrak pigtail wire (Baylis Medical) in the left atrium following transeptal puncture. Transesophageal probe in place.

Video 2. Advancing the Steerable Guide Catheter (Abbott Vascular) over the ProTrak pigtail wire.

Video 3. Advancing the Steerable Guide Catheter past the ECMO cannula.

Video 4. Steerable Guide Catheter positioned in the left atrium along with the ProTrak pigtail wire.

Video 5. Protrak pigtail and Steerable Guide dilator wire removed. MitraClip (Abbott Vascular) advanced into the left atrium.

Video 6. MitraClip positioned in the left atrium, steering down toward the mitral valve.

Video 7. MitraClip positioned and grasping the mitral valve leaflets.

Video 8. After grasping the mitral valve leaflets, the MitraClip is released.

Video 9. The MitraClip delivery system is removed. Steerable Guide Catheter is removed. MitraClip remains in place, attached to the mitral valve leaflets.

 

Case Report

A 65-year-old male initially presented at Druid City Hospital (Tuscaloosa, Alabama) with an acute myocardial infarction. The patient had a history of coronary artery disease and hypertension. A left heart catheterization was performed, with a stent placed in the left circumflex coronary artery. Use of a balloon pump and subsequent intubation led to aspiration pneumonia and an upper gastrointestinal (GI) bleed. The patient continued to decline with symptoms of sepsis present.

He was transported to Princeton Baptist Medical Center (Birmingham, Alabama) for intervention with cardiogenic shock, severe mitral regurgitation, worsening respiratory failure, and increasing pulmonary edema. The patient presented with a transesophageal echocardiogram (TEE) performed on arrival that noted a reduced left ventricular ejection fraction of 25-30% and severe functional versus degenerative versus ischemic mitral regurgitation. There was concern that the muscle that held the mitral valve in place had torn as a result of the heart attack. The patient had emergent veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and was determined not to be a candidate for surgical intervention. The patient’s mortality rate for acute surgical intervention exceeded 80% and his morbidity and mortality risk was 100%. The determined path forward was emergent transcatheter mitral valve repair with the MitraClip (Abbott Vascular) while on VA ECMO.  

Clip Procedure While on ECMO

The patient was brought to the catheterization lab, transferred to the table, and prepped in the usual fashion. He was already intubated and ventilated. The entire process was performed under fluoroscopic and echocardiographic guidance. Right femoral venous access was obtained by switching out the existing Swan catheter. Perclose (Abbott Vascular) preclosure was placed for eventual hemostasis.

Through a 6 French femoral venous sheath, an 0.032-inch Amplatz Extra Stiff guidewire (Cook Medical) was placed into the superior vena cava and the sheath removed. An 8 French SL1 sheath (St. Jude Medical) was advanced over the guidewire into the superior vena cava. Care was taken not to interfere with the ECMO cannula. Using standard technique under transesophageal guidance, the 71cm BRK transeptal needle (St. Jude Medical) was used to obtain a high and posterior puncture. The SL sheath was advanced into the left atrium. A ProTrack pigtail wire (Baylis Medical) was advanced into the left atrium. The 24 French steerable guide catheter was successfully negotiated across the intra-atrial septum and advanced into the left atrium using appropriate maneuvers.

The MitraClip delivery system was then advanced into the left atrium, and the delivery system was placed into a suitable position over the targeted area, under fluoroscopic and echocardiographic guidance. The clip was advanced into the left ventricle and retracted, trapping the leaflets. The mitral regurgitation was evaluated with the clip partially closed and found to be significantly reduced. The regurgitation was essentially eliminated, and the clip was fully closed.

Three-dimensional reconstruction with an en-face view demonstrated an excellent double orifice valve with a definitive tissue bridge formation. A gradient across the mitral valve of 2 mmHg was noted, indicating no significant stenosis was present. Pre- and post-procedural mean left atrial pressure comparisons were noted and were nicely improved. The result was satisfactory. 

The clip was detached from the delivery system in excellent position. The delivery system was removed from the steerable guide catheter and subsequently, the 24 French sheath was removed. Echocardiographic imaging showed no significant intra-atrial flow or shunt. Completion of the previously placed ProGlide preclosure and figure-of-eight sutures effected right femoral venous hemostasis. 

The patient was transported to the cardiac intensive care unit in stable condition with stable hemodynamics and the ECMO support. He remained intubated and in critical fashion with support to wean as his condition allowed. 

Dr. Mustafa Ahmed can be contacted via Laura Clark at laurag.clark@tenethealth.com and can be followed at @MustafaAhmedMD on Twitter.

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