Mitral valve with three orifices after percutaneous repair with the MitraClip system: the triple-orifice technique
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- Paranskaya, L., Kische, S., Bozdag-Turan, I. et al. Clin Res Cardiol (2012) 101: 847. doi:10.1007/s00392-012-0451-3
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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 . 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.
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 .
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 . 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.