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Relevant clinical history and physical exam
A 75 year-old man with a recent diagnosis of Enterococcus faecalis native mitral valve IE four weeks prior on outpatient parenteral antimicrobial therapy presented with recurrent fevers and dyspnea. His medical history was notable for coronary artery disease status post four vessel coronary artery bypass surgery nine years prior, peripheral arterial disease, and type 2 diabetes mellitus. Initial exam was notable for elevated jugular venous pressure and grade III/VI holosystolic murmur at apex.
Relevant test results prior to catheterization
The repeat blood cultures were negative but repeat echocardiography was notable for severe mitral regurgitation (compared to mild four weeks prior) with a smaller vegetation on the atrial surface of the middle segment of the anterior mitral leaflet. In addition, head magnetic resonance imaging demonstrated two acute lacunar infarcts without neurologic sequelae. Despite continued medical therapy, he developed cardiogenic shock and renal failure requiring hemodynamic support.
Relevant catheterization findings
At rest, the resting mean left atrial pressure was severely elevated at 28 mmHg with severely elevated V wave at 54 mmHg. By transesophageal echocardiography, there were two jets of mitral valve regurgitation, one just medial and one just lateral of A2-P2, collectively severe in severity.
Despite continued medical therapy, he developed cardiogenic shock and renal failure requiring hemodynamic support in the intensive care unit. As he was deemed an inoperable candidate, after a heart team discussion, he was felt to be a candidate for transcathe ter mitralvalve repair given his hemodynamic instability.
In the catheterization laboratory, an 18-French DrySeal sheath was placed into the right common femoral vein.Subsequently, a transseptal puncture was performed in the posterior and mid to inferior portion of the fossa ovalis with an 8-French Mullins sheath. The interatrial septum was dilated with an Inoue dilator to facilitate placement ofa diagnostic catheter for continuous hemodynamic monitoring and placement of the standard guiding catheter of the Mitra Clip system.
After obtaining biplane and 3D imaging bytransesophageal echocardiography, the first Mitra Clip was placed in the A3-P3position. The V-wave of the left atrium decreased from 54 mmHg to 41 mmHg butthere was still evidence of more than 2+ residual mitral regurgitation. Assuch, a second Mitra Clip was placed in the A2-P2 position. The V-wave wasfurther reduced to 34 mmHg after the second clip was deployed. Also, thetransmitral gradient was 3 mmHg at a heart rate of 62 bpm with only mildregurgitation.
In summary, the patient had a successfultranscutaneous mitral valve repair with 2 Mitra Clip placement in the A2-P2 andA3-P3 scallops without complications.
The early valve surgery is critical in optimally managing patients with complicated IE. In those with high surgical risk or inoperable risk, percutaneous approach to valve repair may be considered only after a heart team and multidisciplinary discussion.