IJCA-21305; No of Pages 3 International Journal of Cardiology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization Cengiz Ozturk a,⁎, Atila Iyisoy a, Turgay Celik a, Ersel Onrat b, Önder Akci b, Ali Osman Yildirim a, Sait Demirkol a, Murat Unlu a, Sevket Balta a, Hamidullah Haqmal a a b
Gulhane Military Medical Academy, School of Medicine, Department of Cardiology, Etlik, Ankara, Turkey Afyon Kocatepe University, School of Medicine, Department of Cardiology, Afyon, Turkey
a r t i c l e
i n f o
Article history: Received 2 October 2015 Accepted 3 October 2015 Available online xxxx Keywords: Long distance walking man Percutaneous mitral annuloplasty Coronary revascularization
Dear Editor, The percutaneous mitral annuloplasty is now performed more frequently in patients with functional mitral regurgitation (FMR) who had severely depressed systolic function. The FMR is related with significant morbidity and mortality. The functional levels of these patients are very limited because of severe left ventricular dysfunction and mitral insufficiency related with mitral annular dilatation although optimal medical therapy [1–3]. Unfortunately, cardiac surgery for FMR has high perioperative risks. The percutaneous valve interventions such as Carillon device is a novel alternative choice of treatment based on coronary sinus narrowing. There are several recent reports about the improvement of functional status of these patients after successful implantation of the device. There are some reports about the efficacy and safety of percutaneous mitral annuloplasty with the Carillon device in the treatment of FMR in systolic heart failure patients [4–9]. These trials confirmed a considerable improvement of FMR as assessed by both echocardiography and functional tests that are constant up to 24 months after the procedure. Additionally, an apparent decrease in the left ventricular diastolic volume indicates reverse remodeling as a result of the Carillon device implantation. Herein, we report a
⁎ Corresponding author at: Department of Cardiology, Gulhane School of Medicine, Tevfik Saglam St., 06018 Etlik, Ankara, Turkey. E-mail address: [email protected] (C. Ozturk).
case who walked long distance after the implantation of percutaneous mitral annuloplasty device with the Carillon system and coronary revascularization. A 66-year-old male with ischemic heart failure, diabetes mellitus and severe FMR was referred to our clinic. He was severely symptomatic (NHYA classes II–III). There were left ventricular dilatation, global hypokinesia, systolic dysfunction (ejection fraction 25%), and severe FMR on transthoracic echocardiography. There was moderate tricuspid regurgitation and the pulmonary artery systolic pressure was 55 mm Hg. The left ventricular enddiastolic and endsystolic diameters were 82 and 60 mm, respectively. The vena contracta diameter was 14 mm and the left atrium was 53 mm. The 6-minute walk test was 102 m. There was significant stenosis in the proximal and mid part of the left anterior descending artery (LAD), and no significant stenosis on the circumflex (CX) artery and right coronary artery. The patient had previous anterior myocardial infarction. First, three drug eluting stents were implanted to the LAD (Fig. 1). After 2 months, the patient was still symptomatic because of heart failure and severe FMR. We decided to perform percutaneous mitral annuloplasty with the Carillon system (Cardiac Dimensions Inc, Kirkland, WA, USA) to the patient because of the high surgery risk. Under fluoroscopy, 9 F guiding catheter was introduced into the coronary sinus. After the coronary sinus angiography with marked pigtail catheter, the distal anchor of the device was released. After the application of adequate tension, which resulted in a decrease in the degree of MR on echocardiography. No compression was done on the mid part of the CX artery. The proximal anchor of the device was released (Fig. 2). Before completion of the procedure, coronary angiography was performed to ensure lack of coronary artery compression by the device. After this procedure the echo parameters of FMR further improved. The vena contracta diameter of the FMR was 14 mm before the procedure and after the procedure it was 4.5 mm. Annular dilatation was also diminished. After six months of implantation of percutaneous mitral annuloplasty device and stents, the patient was nonsymptomatic (NHYA class I). Left ventricular dilatation was diminished (ejection fraction 34%), and mild degree FMR was observed on transthoracic echocardiography. There was mild tricuspid regurgitation and the pulmonary artery systolic pressure was 30 mm Hg. The left ventricular enddiastolic and endsystolic diameters were 62 and 41 mm,
http://dx.doi.org/10.1016/j.ijcard.2015.10.015 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: C. Ozturk, et al., Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization, Int J Cardiol (2015), http://dx.doi.org/10.1016/j.ijcard.2015.10.015
2
Correspondence
Fig. 1. Coronary angiogram of the patient after coronary stenting.
Fig. 2. The fluoroscopic window of the patient after Carillon device.
respectively. The vena contracta diameter was 3 mm and the left atrium was 40 mm (Figs. 3, 4, 5; Video 1). The 6-minute walk test was 420 m. In conclusion, there was summation of the dual (coronary sinus based annuloplasty with the Carillon system for FMR and coronary intervention for severe stenosis) therapy in our case. They can be done easily in this complex problems. The patient was no symptomatic and he walked 420 m in 6-minute walk. He can do everything easily.
Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.10.015.
Fig. 3. The diminishing of the left ventricular dilatation.
Fig. 4. Echocardiographic imaging of the mild FMR after combined therapy.
Conflict of interest There is no conflict of interest.
Please cite this article as: C. Ozturk, et al., Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization, Int J Cardiol (2015), http://dx.doi.org/10.1016/j.ijcard.2015.10.015
Correspondence
Fig. 5. Vena contracta diameter of the patient.
References [1] M. Chandavimol, F. Málek, A. Ignaszewski, Natural history of moderate to severe mitral regurgitation in patients with cardiomyopathy followed at tertiary care heart failure clinic, Int. J. Cardiol. 115 (2) (Feb 7 2007) e68–e70 (Epub 2006 Oct 12).
3
[2] L.E. Sade, Functional mitral regurgitation, Anadolu Kardiyol. Derg. 9 (Suppl. 1) (Jul 2009) 3–9 (Article in Turkish). [3] L. Oukerraj, T. El Houari, N. El Haitem, R. Bennani, N. Fellat, N. Fikri, R. Mesbahi, M. Benomar, Percutaneous mitral valvuloplasty in patients with low cardiac output at high surgical risk, Int. J. Cardiol. 130 (2) (Nov 12 2008) 285–287 (Epub 2007 Aug 9). [4] N. Messas, H. Samet, J. Brocchi, P. Billaud, H. Kremer, L. Jesel, P. Ohlmann, O. Morel, Mitral valve surgery for transient severe mitral regurgitation: an alternative to medical treatment? Int. J. Cardiol. 175 (3) (Aug 20 2014) e40–e42, http://dx.doi. org/10.1016/j.ijcard.2014.05.041 (Epub 2014 May 17). [5] M. Bartkowiak, P. Bugajski, I. Jedlinski, R. Kalawski, Mitral valve repair in a patient with previous percutaneous annuloplasty with a CARILLON device, Interact. Cardiovasc. Thorac. Surg. 12 (2011) 1054–1056. [6] T. Siminiak, U.C. Hoppe, J. Schofer, et al., Effectiveness and safety of percutaneous coronary sinus-based mitral valve repair in patients with dilated cardiomyopathy (from the AMADEUS trial), Am. J. Cardiol. 104 (2009) 565–570. [7] T. Siminiak, C.W. Wu, M. Haude, et al., Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN trial, Eur. J. Heart Fail. 14 (2012) 931–938. [8] A. Iyisoy, C. Ozturk, M. Unlu, T. Celik, Sait Demirkol, H. Haqmal, Cardiac resynchronization therapy in a patient with percutaneous mitral annuloplasty and prior aortic valve surgery, Int. J. Cardiol. 187 (Apr 3 2015) 532–533, http://dx.doi.org/10.1016/j.ijcard. 2015.04.014 (Epub ahead of print, No abstract available). [9] T. Celik, C. Ozturk, A. Iyisoy, M. Demir, A.O. Yildirim, S. Demirkol, S. Balta, Percutaneous mitral annuloplasty in a patient with coronary sinus stenosis and coronary artery compression during procedure; they will not interfere, Int. J. Cardiol. 191 (Jul 15 2015) 84–86, http://dx.doi.org/10.1016/j.ijcard.2015.04.283 (Epub 2015 May 2, No abstract available).
Please cite this article as: C. Ozturk, et al., Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization, Int J Cardiol (2015), http://dx.doi.org/10.1016/j.ijcard.2015.10.015
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Correspondence
Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization Cengiz Ozturk a,⁎, Atila Iyisoy a, Turgay Celik a, Ersel Onrat b, Önder Akci b, Ali Osman Yildirim a, Sait Demirkol a, Murat Unlu a, Sevket Balta a, Hamidullah Haqmal a a b
Gulhane Military Medical Academy, School of Medicine, Department of Cardiology, Etlik, Ankara, Turkey Afyon Kocatepe University, School of Medicine, Department of Cardiology, Afyon, Turkey
a r t i c l e
i n f o
Article history: Received 2 October 2015 Accepted 3 October 2015 Available online xxxx Keywords: Long distance walking man Percutaneous mitral annuloplasty Coronary revascularization
Dear Editor, The percutaneous mitral annuloplasty is now performed more frequently in patients with functional mitral regurgitation (FMR) who had severely depressed systolic function. The FMR is related with significant morbidity and mortality. The functional levels of these patients are very limited because of severe left ventricular dysfunction and mitral insufficiency related with mitral annular dilatation although optimal medical therapy [1–3]. Unfortunately, cardiac surgery for FMR has high perioperative risks. The percutaneous valve interventions such as Carillon device is a novel alternative choice of treatment based on coronary sinus narrowing. There are several recent reports about the improvement of functional status of these patients after successful implantation of the device. There are some reports about the efficacy and safety of percutaneous mitral annuloplasty with the Carillon device in the treatment of FMR in systolic heart failure patients [4–9]. These trials confirmed a considerable improvement of FMR as assessed by both echocardiography and functional tests that are constant up to 24 months after the procedure. Additionally, an apparent decrease in the left ventricular diastolic volume indicates reverse remodeling as a result of the Carillon device implantation. Herein, we report a
⁎ Corresponding author at: Department of Cardiology, Gulhane School of Medicine, Tevfik Saglam St., 06018 Etlik, Ankara, Turkey. E-mail address: [email protected] (C. Ozturk).
case who walked long distance after the implantation of percutaneous mitral annuloplasty device with the Carillon system and coronary revascularization. A 66-year-old male with ischemic heart failure, diabetes mellitus and severe FMR was referred to our clinic. He was severely symptomatic (NHYA classes II–III). There were left ventricular dilatation, global hypokinesia, systolic dysfunction (ejection fraction 25%), and severe FMR on transthoracic echocardiography. There was moderate tricuspid regurgitation and the pulmonary artery systolic pressure was 55 mm Hg. The left ventricular enddiastolic and endsystolic diameters were 82 and 60 mm, respectively. The vena contracta diameter was 14 mm and the left atrium was 53 mm. The 6-minute walk test was 102 m. There was significant stenosis in the proximal and mid part of the left anterior descending artery (LAD), and no significant stenosis on the circumflex (CX) artery and right coronary artery. The patient had previous anterior myocardial infarction. First, three drug eluting stents were implanted to the LAD (Fig. 1). After 2 months, the patient was still symptomatic because of heart failure and severe FMR. We decided to perform percutaneous mitral annuloplasty with the Carillon system (Cardiac Dimensions Inc, Kirkland, WA, USA) to the patient because of the high surgery risk. Under fluoroscopy, 9 F guiding catheter was introduced into the coronary sinus. After the coronary sinus angiography with marked pigtail catheter, the distal anchor of the device was released. After the application of adequate tension, which resulted in a decrease in the degree of MR on echocardiography. No compression was done on the mid part of the CX artery. The proximal anchor of the device was released (Fig. 2). Before completion of the procedure, coronary angiography was performed to ensure lack of coronary artery compression by the device. After this procedure the echo parameters of FMR further improved. The vena contracta diameter of the FMR was 14 mm before the procedure and after the procedure it was 4.5 mm. Annular dilatation was also diminished. After six months of implantation of percutaneous mitral annuloplasty device and stents, the patient was nonsymptomatic (NHYA class I). Left ventricular dilatation was diminished (ejection fraction 34%), and mild degree FMR was observed on transthoracic echocardiography. There was mild tricuspid regurgitation and the pulmonary artery systolic pressure was 30 mm Hg. The left ventricular enddiastolic and endsystolic diameters were 62 and 41 mm,
http://dx.doi.org/10.1016/j.ijcard.2015.10.015 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article as: C. Ozturk, et al., Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization, Int J Cardiol (2015), http://dx.doi.org/10.1016/j.ijcard.2015.10.015
2
Correspondence
Fig. 1. Coronary angiogram of the patient after coronary stenting.
Fig. 2. The fluoroscopic window of the patient after Carillon device.
respectively. The vena contracta diameter was 3 mm and the left atrium was 40 mm (Figs. 3, 4, 5; Video 1). The 6-minute walk test was 420 m. In conclusion, there was summation of the dual (coronary sinus based annuloplasty with the Carillon system for FMR and coronary intervention for severe stenosis) therapy in our case. They can be done easily in this complex problems. The patient was no symptomatic and he walked 420 m in 6-minute walk. He can do everything easily.
Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.10.015.
Fig. 3. The diminishing of the left ventricular dilatation.
Fig. 4. Echocardiographic imaging of the mild FMR after combined therapy.
Conflict of interest There is no conflict of interest.
Please cite this article as: C. Ozturk, et al., Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization, Int J Cardiol (2015), http://dx.doi.org/10.1016/j.ijcard.2015.10.015
Correspondence
Fig. 5. Vena contracta diameter of the patient.
References [1] M. Chandavimol, F. Málek, A. Ignaszewski, Natural history of moderate to severe mitral regurgitation in patients with cardiomyopathy followed at tertiary care heart failure clinic, Int. J. Cardiol. 115 (2) (Feb 7 2007) e68–e70 (Epub 2006 Oct 12).
3
[2] L.E. Sade, Functional mitral regurgitation, Anadolu Kardiyol. Derg. 9 (Suppl. 1) (Jul 2009) 3–9 (Article in Turkish). [3] L. Oukerraj, T. El Houari, N. El Haitem, R. Bennani, N. Fellat, N. Fikri, R. Mesbahi, M. Benomar, Percutaneous mitral valvuloplasty in patients with low cardiac output at high surgical risk, Int. J. Cardiol. 130 (2) (Nov 12 2008) 285–287 (Epub 2007 Aug 9). [4] N. Messas, H. Samet, J. Brocchi, P. Billaud, H. Kremer, L. Jesel, P. Ohlmann, O. Morel, Mitral valve surgery for transient severe mitral regurgitation: an alternative to medical treatment? Int. J. Cardiol. 175 (3) (Aug 20 2014) e40–e42, http://dx.doi. org/10.1016/j.ijcard.2014.05.041 (Epub 2014 May 17). [5] M. Bartkowiak, P. Bugajski, I. Jedlinski, R. Kalawski, Mitral valve repair in a patient with previous percutaneous annuloplasty with a CARILLON device, Interact. Cardiovasc. Thorac. Surg. 12 (2011) 1054–1056. [6] T. Siminiak, U.C. Hoppe, J. Schofer, et al., Effectiveness and safety of percutaneous coronary sinus-based mitral valve repair in patients with dilated cardiomyopathy (from the AMADEUS trial), Am. J. Cardiol. 104 (2009) 565–570. [7] T. Siminiak, C.W. Wu, M. Haude, et al., Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN trial, Eur. J. Heart Fail. 14 (2012) 931–938. [8] A. Iyisoy, C. Ozturk, M. Unlu, T. Celik, Sait Demirkol, H. Haqmal, Cardiac resynchronization therapy in a patient with percutaneous mitral annuloplasty and prior aortic valve surgery, Int. J. Cardiol. 187 (Apr 3 2015) 532–533, http://dx.doi.org/10.1016/j.ijcard. 2015.04.014 (Epub ahead of print, No abstract available). [9] T. Celik, C. Ozturk, A. Iyisoy, M. Demir, A.O. Yildirim, S. Demirkol, S. Balta, Percutaneous mitral annuloplasty in a patient with coronary sinus stenosis and coronary artery compression during procedure; they will not interfere, Int. J. Cardiol. 191 (Jul 15 2015) 84–86, http://dx.doi.org/10.1016/j.ijcard.2015.04.283 (Epub 2015 May 2, No abstract available).
Please cite this article as: C. Ozturk, et al., Long distance walking man after a combination of percutaneous mitral annuloplasty and coronary revascularization, Int J Cardiol (2015), http://dx.doi.org/10.1016/j.ijcard.2015.10.015
