Clinical Research in Cardiology

, Volume 101, Issue 10, pp 847–849

Mitral valve with three orifices after percutaneous repair with the MitraClip system: the triple-orifice technique


  • L. Paranskaya
    • Heart Center RostockUniversity Hospital Rostock
  • S. Kische
    • Heart Center RostockUniversity Hospital Rostock
  • I. Bozdag-Turan
    • Heart Center RostockUniversity Hospital Rostock
  • C. Nienaber
    • Heart Center RostockUniversity Hospital Rostock
    • Heart Center RostockUniversity Hospital Rostock
Letter to the Editors

DOI: 10.1007/s00392-012-0451-3

Cite this article as:
Paranskaya, L., Kische, S., Bozdag-Turan, I. et al. Clin Res Cardiol (2012) 101: 847. doi:10.1007/s00392-012-0451-3


Severe mitral regurgitation (MR) is the second most common valve disease requiring surgical treatment in Europe. Consensus exists that valvular surgery should be advised in symptomatic patients with severe MR, as shown by the corresponding class I recommendation in both the American and European clinical guidelines. Mitral valve (MV) repair is the preferred surgical treatment in patients with severe MR [1]. Early trials suggested that percutaneous valve repair with the MitraClip® system (Abbott, USA), that mimics the surgical Alfieri technique, is feasible, safe, and 60 % of the patients are handled with a single clip [2, 3]. This case report illustrates a successful multiple clip approach creating three orifices instead of the classical double one.

A 71-year-old female patient with severe ischemic MV insufficiency and high risk (Logistic EuroSCORE 32.56 %, STS score 20.8 %) was referred to our center for an interventional valve repair with the MitraClip®-System. Echocardiography demonstrated a left-ventricle in the upper range value (end-diastolic diameter 59 mm, end-diastolic volume 160 ml) with a severe reduced ejection fraction of 26 %, a functional MR grade 3 with a regurgitation fraction of 69 % and a vena contracta of 0.8 cm. Due to the mitral pathology and based on our experience, we opted for a multiple clip approach [4]. A first clip was implanted medially with reduction of the MR to grade 2 and in transmitral mean gradient (TMG) of 1.6 mmHg. Implantation of a second clip in lateral position resulted in a reduction of the MR to grade 1 to 2 with TMG of 2.5 mmHg. Implantation of a third clip resulted in a reduction of the MR to a trivial degree of reflux (Fig. 1). As a result, we created three orifices instead of the classical double orifice after the MitraClip repair. Echocardiographic reassessment excluded a significant mitral stenosis (TMG of 3 mmHg, mitral orifice area (MOA) of 2.46 cm²) (Fig. 2). The patient was discharge 5 days after intervention. At baseline, New York Heart Association (NYHA) functional class was III with improvement to NYHA class I–II 3 months after the procedure. As a result of the drastic reduction in left ventricular pre-load, follow-up at 3 months demonstrated a significant increase of ejection fraction to 38 % and a decrease of pulmonary artery pressure from 60 to 32 mmHg. Notably, there was residual MR and no sign of mitral valve stenosis.
Fig. 1

Postprocedural two-dimensional transesophageal echocardiography demonstrates the preprocedural echo (a), a reduction of MR after placement of the first clip (b), the second clip (c) and a trivial MR after third clip (d)
Fig. 2

a Three-dimensional transesophageal echocardiography after intervention with confirmation of three orifices (arrows). b Assessment of the mitral orifice area (2.46 cm2 by Philips-QULAB)

The MitraClip concept of creating a double orifice is the standard for the majority of patients but may not be applied to all high-risk patients with severe MR. A considerable number of patients with secondary MR and advanced heart failure may present with excessive annular dilation and extensive defect in mitral valve leaflets coaptation. This condition may be better handled by placing three clips (resulting in a triple orifice MV) to better approximate the leaflets and distribute the tension on a larger area. As our goal is to achieve almost complete correction of the MR, in this particular case, a third clip was added after the second one even if the MR jet was already reduced to degree 2. Furthermore, a single MitraClip can not always address a complex MR secondary to abnormal function of different segments of the MV. Our group described the first application of the ‘‘zipping technique’’ in a patient with end-stage heart failure, who was not a suitable candidate for the standard single-clip strategy. With the elective first in-human application of four clips, a profound reduction of MR grade was accomplished by creation of a lateral neo-orifice instead of a double orifice [5].

Although the creation of a triple orifice valve after MitraClip implantation is not rare, to the best of our knowledge, this case describes such an occurrence for the first time. In fact, we report a triple-orifice MV after a multiple clip approach in a high-risk patient for the first time. This approach led to a significant reduction of MR and an improvement of the NYHA class. Furthermore, no pathological reduction of the MOA was noticed. Precise assessment of the transvalvular MV gradient and MOA is mandatory to prevent severe mitral stenosis with this unconventional approach. The adding of 3D-TEE for a complex approach should contribute to a higher success rate of intervention [2]. Until more experience can be gained, this new technology should only be applied for a high-risk population in whom no viable option for mitral repair is available, and further investigation is required to further define patient populations that will benefit most. Our triple-orifice technique should be integrated in that context and it needs to be determined whether successful application of our triple-orifice technique leads to sustained reverse ventricular remodeling and will translate into an improved long-term prognosis in patients in whom no other viable option for mitral valve repair is available.

Conflict of interest

No conflict of interest.

Copyright information

© Springer-Verlag 2012