Author + information
Patient initials or identifier number
Relevant clinical history and physical exam
The 42 years old male had,
1. Marfan syndrome with aortic root dilatation and mild aortic regurgitation,post modified bentall's operation in 2006
2. Mitral valve prolapse with severe MR
3. Ectopic lentitis OU, post lens extraction OU in 2000
4. Dural ectasia. He complained abdominal distension, poor appetite since middle of October/2016.
A Sudden onset chest tightness and dyspnea happened on 10/26, then he came to our hospital.PE revealed bilateral lower lung rales, acute decompensated heart failure related
Relevant test results prior to catheterization
TEE revealed acute ruptured cordae tendine with A3 flail, P1 severe prolapse with severe mitral regurgitation
Relevant catheterization findings
TEE showed bilateral atrium severe dilatation, severe RV systolic dysfunction and mild left ventricle systolic dysfunction
Under the general anesthesia, we punctured through the right femoral vein. Then we performed transeptal puncture under real-time TEE guiding with SL0 with a BRK1 needle. After confirmed the tip was in LA, we changed the GW with 1 cm Amplatz Super stiff GW into LUPV and dilated the vessel with 16 Fr and 18Fr dilator. Next, we advance the Steerable Guide with Dilator into LA and removed the dilator and wire sequentially. Following we advanced the Clip Delivery System into LA and positioning the system into correct trajectory. Then we opened the clip arm to 180 degree and dive into LV. At LV, we closed the clip to 120 degrees and grasped medial site of anterior and posterior leaflet as possible. Because of a broad area of medial regurgitation jet(A3) and another jet from lateral site(P1), it's difficult to reduce the MR by single clip strategy. Therefore, after 1st clip, we added 2nd clip over lateral site of mitral valve. Then, there were moderate regurgitation jet from medial site of 1st clip, so we added 3rd clip at medial site of 1st clip. The MR severity turned into trivial, mean pressure gradient was 3 mmHg. After removed deliver system, bidirectional shunt was noticed at iatrogenic ASD site, we checked aterial blood gas and hypoxemia reported (PaO2 decreased from 90 to 77, then 70 mmHg). So a 12 mm ASD occluder was deployed. The puncture wound was closed by figure 8 suture and the patient was sent to intensive care unit for further care.
A emergent MitraClip can be life saving procedure for acute chordae ruptured patient with biventricular dysfunction.
Right ventricle failure and elevated right atrium pressure may predict the requirement of ASD occluder.