https://orcid.org/0000-0002-4677-2829
A 90-year-old man with a 3-month history of exertional dyspnea was hospitalized for worsening heart failure. Transthoracic echocardiography (TTE) showed severe mitral regurgitation (MR) with eccentric jets, normal left ventricular function and mild-to-moderate aortic regurgitation (Supplementary data online, Video S1). Three-dimensional (3D) transoesophageal echocardiography (TEE) confirmed severe MR with two jets due to P1 prolapse and A2 leaflet degeneration and the presence of double-orifice mitral valve (DOMV) (Figure 1A and B, Supplementary data online, Videos S2 and S3). The medial and lateral mitral valve (MV) areas were measured using multi-planar reconstruction (MPR) derived from 3D TEE as 3.1 and 2.1 cm2, respectively and no mitral stenosis (MS) was observed [mean MV pressure gradient (PG) 1 mmHg]. The heart team determined to perform MitraClip (Abbott Vascular, CA) implantation because of the patient’s high surgical risk (STS score for MV replacement 15.3%). The MitraClip procedure was performed through the right femoral vein under general anaesthesia and TEE guidance. The MR jets were primarily caused by P1 prolapse (3D vena contracta area: P1 prolapse 0.43 cm2, A2 leaflet degeneration 0.18 cm2). Therefore, the A1-P1 segment was grasped with the MitraClip-G4 NT using Live MPR mode (Figure 1C), resulting in mild-to-moderate residual MR with no evidence of MS (mean MV PG 1–2 mmHg) (Figure 1D–F and Supplementary data online, Videos S4 and S5). The patient’s symptoms improved and TTE 1 month after the procedure revealed a similar grade of MR (Supplementary data online, Video S6).
(A) 3D TEE imaging at baseline. The yellow arrow and white asterisk indicate a bridge connecting the anterior and posterior leaflets and each MV foramen, respectively. (B) 2D TEE imaging of bi-commissure view with colour. (C) Live MPR mode imaging derived from 3D TEE when grasping the A1-P1 segment with MitraClip. (D-F) Final intra-procedural imaging. (D); angiography, (E); 2D TEE imaging with colour-compare mode, (F); 3D TEE imaging. The red triangle shows the grasped leaflet.
DOMV—a rare congenital malformation characterized by MV with two opening orifices—is usually diagnosed in childhood because of its association with other congenital heart defects, such as partial atrioventricular septal defects or aortic coarctation. This case underscores that the MitraClip procedure can be performed effectively under sufficient evaluation with echocardiography even in patients with severe MR and very complex MV anatomy.
Acknowledgements: The authors would like to thank Akiho Seno, Riyo Ogura, and Keitaro Mahara for assistance during this procedure.
Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.
Funding: No funding was provided for this report.
Data availability: The data underlying this article will be shared on reasonable request to the corresponding author.
Author notes
Conflict of interest: The authors declare that they have no conflict of interests that could prejudice the impartiality of this report.
