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Severe mitral regurgitation (MR) in patients after cardiac transplant has not been well studied. Traditionally, patients have undergone corrective surgery. We report a 64-year-old man who presented with new heart failure symptoms 6 months after cardiac transplantation. He was found to have severe MR and underwent successful implantation of a MitraClip® with reduction of his MR to mild as well as improvement in his symptoms. Six months later he was still doing well, and a repeat echocardiogram showed good results. We found two previously reported cases using the MitraClip to treat severe MR in adult cardiac transplant patients. The MitraClip is a viable treatment option for MR in cardiac transplant patients despite their distorted anatomy.
In nontransplant patients at prohibitive surgical risk, the MitraClip® (Abbot Vascular, Santa Clara, CA) provides a therapeutic treatment option for mitral regurgitation (MR). The MitraClip is a Food and Drug Administration–approved percutaneous mitral valve repair system for severe degenerative MR. Current trials are evaluating its role in functional regurgitation. The system utilizes a cobalt-chromium clip covered with a polypropylene fabric to grasp the mitral leaflets, thus reducing regurgitation by increasing leaflet coaptation. Insertion of the MitraClip is a challenging procedure and must be performed by a well-trained team under fluoroscopic and echocardiographic guidance.
Traditionally, severe mitral valve disease after transplantation has been addressed by a surgical approach (1–3). Unfortunately, many patients may be at high surgical risk for complications due to comorbidities, functional status, and need for repeat sternotomy. It has not been well studied how best to treat these high-risk patients and whether the MitraClip is a feasible and safe option in this population.
A 64-year-old man with idiopathic dilated cardiomyopathy underwent cardiac transplantation for end-stage heart failure. He had a prolonged postoperative course complicated by primary graft dysfunction, respiratory failure requiring tracheostomy, renal failure, and malnutrition. After an extended hospital and rehabilitation stay, he did make significant functional recovery on goal-directed medical therapy. Six months after transplantation, he developed symptoms concerning of heart failure. Acute cellular rejection was ruled out. A repeat echocardiogram showed mild to moderately depressed systolic function (stable posttransplant) and severe functional MR (vena contracta, 0.7 cm; proximal isovelocity surface area, 0.8 cm; effective regurgitant orifice area, 0.3 cm2; systemic blunting of pulmonary venous flow) due to a retracted posterior leaflet and failure to coapt adequately (Figure 1).
Given his medical comorbidities, poor functional status, and need for another sternotomy, he was deemed to be a high-risk surgical candidate. The decision was made for him to undergo treatment with a MitraClip. The procedure was performed using both fluoroscopy and 3-dimensional transesophageal guidance. The standard right femoral venous approach was used to gain access for the MitraClip apparatus. A transseptal puncture was performed to gain access into the left atrium from the right atrium. A single MitraClip was successfully placed across the A2-P2 leaflets of the mitral valve. Confirmation of correct placement was obtained via concurrent transesophageal echocardiography, with reduction of the MR from severe to mild (Figure 2). The patient was seen in the clinic 6 months after the procedure and was doing well, with improvement in his symptoms and functional status. A repeat echocardiogram showed sustained reduction of the MR with the MitraClip.
Our case highlights the potential role for the MitraClip device in treating severe MR in adult cardiac transplant patients who are at high risk for mitral valve surgery. As the MitraClip is a relatively novel device, there is limited data for its use in cardiac transplant recipients. Our review revealed two other reported cases in which the MitraClip device was used to treat MR in a cardiac transplant patient. Ferraro et al (4) reported a patient who presented almost 20 years posttransplantation with severe degenerative MR. He underwent successful placement of two MitraClips with reduction from severe to mild MR. Iorio et al (5) reported a patient who presented approximately 1 year posttransplantation with severe MR secondary to a prolapsed leaflet and failure of adequate coaptation. Their patient also had successful reduction of his MR after MitraClip placement. The MitraClip may be a feasible option for post–cardiac transplant patients with severe MR who are at high surgical risk.