Author + information
- Rodrigo Estévez-Loureiro, MD, PhD∗ (, )
- Dabit Arzamendi, MD, MSc,
- Xavier Freixa, MD, PhD,
- Rosa Cardenal, MD,
- Fernando Carrasco-Chinchilla, MD, PhD,
- Ana Serrador-Frutos, MD, PhD,
- Manuel Pan, MD, PhD,
- Manel Sabaté, MD, PhD,
- Jose Diaz, MD,
- Jose María Hernández, MD, PhD,
- Antonio Serra, MD, PhD,
- Felipe Fernández-Vázquez, MD, PhD,
- Spanish Working Group on MitraClip
- ↵∗Interventional Cardiology, Hospital de León, Altos de Nava SN, 24008 León, Spain
Data from real-world registries have shown that in a high-risk population, the transcatheter mitral valve repair technique is associated with a persistent reduction in mitral regurgitation (MR) severity and relevant improvement in New York Heart Association (NYHA) functional class (1). Acute MR may develop in the setting of an acute myocardial infarction (AMI) as a result of papillary muscle dysfunction or rupture, but these patients are grossly underrepresented in MitraClip (Abbott Vascular, Santa Clara, California) registries. Although the use of this technology for correcting MR after AMI has been previously reported (2), data on consecutive patients treated for this condition are lacking. Thus, we aimed to report our initial experience with transcatheter mitral valve repair technology implantation in patients with acute MR after AMI.
From October 2010 to January 2015, a total of 185 patients were treated with transcatheter mitral valve repair technology and prospectively included in our national database. During this period, 5 patients (2.7%) were identified as being treated in the setting of AMI. Baseline, procedural, and follow-up characteristics are shown in Table 1. The patients presented high logistic EuroScore values (median 29.1%) and 4 of 5 patients were on pharmacological or mechanical left ventricular (LV) support. Although most procedures were performed in a subacute phase, 2 procedures were carried out 1 month after admission. This fact reflects the use of this therapy as a bailout strategy in critically ill patients with severe difficulties in the weaning from mechanical ventilation. Acute procedural success was achieved in all cases with a median of 2 clips per patient. As shown in Table 1, the findings associated with MR reduction and mitral valve gradients were satisfactory. Pulmonary artery pressure decreased from a median of 62 mm Hg to 38 mm Hg. No major complications were observed after the procedure. However, patient 5 died of multiorgan failure after 1 week of hospitalization. The survivors had a short hospital stay after the procedure (median, 7.5 days), reflecting the rapid recovery once hemodynamic conditions improved. Four patients were followed for a median of 317 days, with all of them having an MR ≤2+ and in NYHA functional class ≤II.
The vast majority of the transcatheter mitral valve repair procedures performed to date correspond to patients with advanced functional class but chronic MR and a stable clinical situation. Acute ischemic MR is a life-threatening complication associated with high rates of morbidity and mortality even when surgically corrected (3). Our data show that this technology has proved to be a safe and effective alternative to surgical intervention in these unstable patients. Potential advantages of this therapy are, first, the rapid decrease in LV, left atrial, and pulmonary artery pressures and the increase in cardiac output observed after a successful correction of the MR (4), and, second, the avoidance of the LV damage induced by the systemic inflammatory response, free radical injury, and myocardial oxidative stress associated with cardiopulmonary bypass (5). Moreover, transcatheter mitral valve repair technology also may avoid the restraint of the mitral annular motion caused by mitral rings or prosthesis and the development of abnormal septal motion. In addition, acute MR usually develops in a previously normal mitral valve, which usually translates in optimal leaflet tissue and coaptation for this therapy.
Our study has several limitations. First, the sample size is very small, and our results should be interpreted with caution. Larger series with longer follow-up are mandatory to clarify the effect of this technology in this scenario. Second, surgery is still the gold standard for treating acute MR in AMI patients, and this therapy should be offered to patients deemed at high surgical risk or inoperable by the heart team.
In conclusion, the treatment of acute MR with transcatheter mitral valve repair technology in AMI patients appears to be safe and effective, leading to a rapid clinical recovery and persistent clinical improvement at follow-up. These findings may help to expand the clinical indications of this technology in more acute settings.
Please note: Drs. Arzamendi, Freixa, Carrasco-Chinchilla, Pan, Hernández, and Serra have received speakers’ fees from Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Nickenig G.,
- Estevez-Loureiro R.,
- Franzen O.,
- et al.
- Chevalier P.,
- Burri H.,
- Fahrat F.,
- et al.
- Siegel R.J.,
- Biner S.,
- Rafique A.M.,
- et al.
- van Boven W.J.,
- Gerritsen W.B.,
- Driessen A.H.,
- et al.