JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 66, NO. 1, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
Letters Percutaneous Mitral Valve Repair for Acute Mitral Regurgitation After an Acute Myocardial Infarction
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 #2þ and in NYHA functional
Data from real-world registries have shown that
class #II.
in a high-risk population, the transcatheter mitral
The vast majority of the transcatheter mitral
valve repair technique is associated with a persis-
valve repair procedures performed to date corre-
tent reduction in mitral regurgitation (MR) severity
spond to patients with advanced functional class
and relevant improvement in New York Heart As-
but chronic MR and a stable clinical situation. Acute
sociation (NYHA) functional class (1). Acute MR
ischemic
may develop in the setting of an acute myo-
associated with high rates of morbidity and mor-
cardial infarction (AMI) as a result of papillary
tality even when surgically corrected (3). Our data
muscle dysfunction or rupture, but these patients
show that this technology has proved to be a safe
are grossly underrepresented in MitraClip (Abbott
and effective alternative to surgical intervention in
Vascular, Santa Clara, California) registries. Al-
these unstable patients. Potential advantages of this
though the use of this technology for correcting
therapy are, first, the rapid decrease in LV, left
MR after AMI has been previously reported (2), data
atrial, and pulmonary artery pressures and the in-
on consecutive patients treated for this condition
crease in cardiac output observed after a successful
are lacking. Thus, we aimed to report our initial
correction of the MR (4), and, second, the avoidance
experience with transcatheter mitral valve repair
of the LV damage induced by the systemic inflam-
technology implantation in patients with acute MR
matory response, free radical injury, and myocardial
after AMI.
oxidative stress associated with cardiopulmonary
MR
is
a
life-threatening
complication
From October 2010 to January 2015, a total of 185
bypass (5). Moreover, transcatheter mitral valve
patients were treated with transcatheter mitral
repair technology also may avoid the restraint of
valve repair technology and prospectively included
the mitral annular motion caused by mitral rings or
in our national database. During this period, 5 pa-
prosthesis and the development of abnormal septal
tients (2.7%) were identified as being treated in the
motion. In addition, acute MR usually develops in a
setting of AMI. Baseline, procedural, and follow-up
previously
characteristics are shown in Table 1. The patients
translates in optimal leaflet tissue and coaptation
presented high logistic EuroScore values (median
for this therapy.
29.1%) and 4 of 5 patients were on pharmacological or
mechanical
left
ventricular
(LV)
normal
mitral
valve,
which
usually
Our study has several limitations. First, the sample
support.
size is very small, and our results should be in-
Although most procedures were performed in a
terpreted with caution. Larger series with longer
subacute phase, 2 procedures were carried out 1
follow-up are mandatory to clarify the effect of this
month after admission. This fact reflects the use of
technology in this scenario. Second, surgery is still
this therapy as a bailout strategy in critically ill
the gold standard for treating acute MR in AMI pa-
patients with severe difficulties in the weaning from
tients, and this therapy should be offered to patients
mechanical ventilation. Acute procedural success
deemed at high surgical risk or inoperable by the
was achieved in all cases with a median of 2
heart team.
clips per patient. As shown in Table 1, the findings
In conclusion, the treatment of acute MR with
associated with MR reduction and mitral valve gradi-
transcatheter mitral valve repair technology in AMI
ents were satisfactory. Pulmonary artery pressure
patients appears to be safe and effective, leading to
decreased from a median of 62 mm Hg to 38 mm Hg.
a rapid clinical recovery and persistent clinical
92
JACC VOL. 66, NO. 1, 2015
Letters
JULY 7, 2015:91–9
T A B L E 1 Patient Characteristics, Procedural Details, and Follow-Up Data
Age, yrs Type of MI NYHA functional class IV/cardiogenic shock Logistic EuroScore, % Interval between MI and clip, days
Patient #1
Patient #2
Patient #3
Patient #4
76
51
76
72
Patient #5
66
STEMI
STEMI
NSTEMI
NSTEMI
STEMI
Class IV
Cardiogenic shock
Class IV
Cardiogenic shock
Cardiogenic shock
29.1
38.3
68.1
15
22.6
9
33
49
12
8
Pre-procedural LVEF, %
65
43
23
48
16
MR grade
4þ
4þ
4þ
4þ
4þ
Papillary muscle rupture
No
No
No
No
No
Systolic PAP, mm Hg
58
62
70
50
65
Device success
Yes
Yes
Yes
Yes
Yes
Number of clips
2
2
2
1
3
Device time, min*
140
150
138
60
90
LV support
No
IABP
Inotropes
IABP
IABP 2þ
Procedural
Post-procedural 1–2þ
2þ
Trace
Trace
MV area, cm2
MR grade
1.8
2.1
3.3
3
4
MV gradient, mm Hg
4.5
3.1
1.8
3.8
3.5 2þ
Follow-up MR grade
2þ
2þ
1þ
1þ
LVEF, %
60
45
20
50
15
Systolic PAP, mm Hg
30
38
42
32
60
NYHA functional class
II
II
II
I
IV/death during admission
*Device time: from transseptal puncture to deployment of the clip. IABP ¼ intra-aortic balloon pump; LV ¼ left ventricular; LVEF ¼ left ventricular ejection fraction; MI ¼ myocardial infarction; MR ¼ mitral regurgitation; MV ¼ mitral valve; NSTEMI ¼ non–ST-segment elevation myocardial infarction; NYHA ¼ New York Heart Association; PAP ¼ pulmonary artery pressure; STEMI ¼ ST-segment elevation myocardial infarction.
improvement at follow-up. These findings may help
http://dx.doi.org/10.1016/j.jacc.2015.03.597
to expand the clinical indications of this technology
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.
in more acute settings. *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 on behalf of the Spanish Working Group on MitraClip *Interventional Cardiology, Hospital de León Altos de Nava SN 24008 León Spain E-mail: [email protected]
REFERENCES 1. Nickenig G, Estevez-Loureiro R, Franzen O, et al. Percutaneous mitral valve edge-to-edge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011-2012 Pilot European Sentinel Registry. J Am Coll Cardiol 2014;64: 875–84. 2. Bilge M, Alemdar R, Yasar AS. Successful percutaneous mitral valve repair with the MitraClip system of acute mitral regurgitation due to papillary muscle rupture as complication of acute myocardial infarction. Catheter Cardiovasc Interv 2014;83:E137–40. 3. Chevalier P, Burri H, Fahrat F, et al. Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation. Eur J Cardiothorac Surg 2004;26:330–5. 4. Siegel RJ, Biner S, Rafique AM, et al. The acute hemodynamic effects of MitraClip therapy. J Am Coll Cardiol 2011;57:1658–65. 5. van Boven WJ, Gerritsen WB, Driessen AH, et al. Myocardial oxidative stress, and cell injury comparing three different techniques for coronary artery bypass grafting. Eur J Cardiothorac Surg 2008;34: 969–75.
VOL. 66, NO. 1, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
Letters Percutaneous Mitral Valve Repair for Acute Mitral Regurgitation After an Acute Myocardial Infarction
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 #2þ and in NYHA functional
Data from real-world registries have shown that
class #II.
in a high-risk population, the transcatheter mitral
The vast majority of the transcatheter mitral
valve repair technique is associated with a persis-
valve repair procedures performed to date corre-
tent reduction in mitral regurgitation (MR) severity
spond to patients with advanced functional class
and relevant improvement in New York Heart As-
but chronic MR and a stable clinical situation. Acute
sociation (NYHA) functional class (1). Acute MR
ischemic
may develop in the setting of an acute myo-
associated with high rates of morbidity and mor-
cardial infarction (AMI) as a result of papillary
tality even when surgically corrected (3). Our data
muscle dysfunction or rupture, but these patients
show that this technology has proved to be a safe
are grossly underrepresented in MitraClip (Abbott
and effective alternative to surgical intervention in
Vascular, Santa Clara, California) registries. Al-
these unstable patients. Potential advantages of this
though the use of this technology for correcting
therapy are, first, the rapid decrease in LV, left
MR after AMI has been previously reported (2), data
atrial, and pulmonary artery pressures and the in-
on consecutive patients treated for this condition
crease in cardiac output observed after a successful
are lacking. Thus, we aimed to report our initial
correction of the MR (4), and, second, the avoidance
experience with transcatheter mitral valve repair
of the LV damage induced by the systemic inflam-
technology implantation in patients with acute MR
matory response, free radical injury, and myocardial
after AMI.
oxidative stress associated with cardiopulmonary
MR
is
a
life-threatening
complication
From October 2010 to January 2015, a total of 185
bypass (5). Moreover, transcatheter mitral valve
patients were treated with transcatheter mitral
repair technology also may avoid the restraint of
valve repair technology and prospectively included
the mitral annular motion caused by mitral rings or
in our national database. During this period, 5 pa-
prosthesis and the development of abnormal septal
tients (2.7%) were identified as being treated in the
motion. In addition, acute MR usually develops in a
setting of AMI. Baseline, procedural, and follow-up
previously
characteristics are shown in Table 1. The patients
translates in optimal leaflet tissue and coaptation
presented high logistic EuroScore values (median
for this therapy.
29.1%) and 4 of 5 patients were on pharmacological or
mechanical
left
ventricular
(LV)
normal
mitral
valve,
which
usually
Our study has several limitations. First, the sample
support.
size is very small, and our results should be in-
Although most procedures were performed in a
terpreted with caution. Larger series with longer
subacute phase, 2 procedures were carried out 1
follow-up are mandatory to clarify the effect of this
month after admission. This fact reflects the use of
technology in this scenario. Second, surgery is still
this therapy as a bailout strategy in critically ill
the gold standard for treating acute MR in AMI pa-
patients with severe difficulties in the weaning from
tients, and this therapy should be offered to patients
mechanical ventilation. Acute procedural success
deemed at high surgical risk or inoperable by the
was achieved in all cases with a median of 2
heart team.
clips per patient. As shown in Table 1, the findings
In conclusion, the treatment of acute MR with
associated with MR reduction and mitral valve gradi-
transcatheter mitral valve repair technology in AMI
ents were satisfactory. Pulmonary artery pressure
patients appears to be safe and effective, leading to
decreased from a median of 62 mm Hg to 38 mm Hg.
a rapid clinical recovery and persistent clinical
92
JACC VOL. 66, NO. 1, 2015
Letters
JULY 7, 2015:91–9
T A B L E 1 Patient Characteristics, Procedural Details, and Follow-Up Data
Age, yrs Type of MI NYHA functional class IV/cardiogenic shock Logistic EuroScore, % Interval between MI and clip, days
Patient #1
Patient #2
Patient #3
Patient #4
76
51
76
72
Patient #5
66
STEMI
STEMI
NSTEMI
NSTEMI
STEMI
Class IV
Cardiogenic shock
Class IV
Cardiogenic shock
Cardiogenic shock
29.1
38.3
68.1
15
22.6
9
33
49
12
8
Pre-procedural LVEF, %
65
43
23
48
16
MR grade
4þ
4þ
4þ
4þ
4þ
Papillary muscle rupture
No
No
No
No
No
Systolic PAP, mm Hg
58
62
70
50
65
Device success
Yes
Yes
Yes
Yes
Yes
Number of clips
2
2
2
1
3
Device time, min*
140
150
138
60
90
LV support
No
IABP
Inotropes
IABP
IABP 2þ
Procedural
Post-procedural 1–2þ
2þ
Trace
Trace
MV area, cm2
MR grade
1.8
2.1
3.3
3
4
MV gradient, mm Hg
4.5
3.1
1.8
3.8
3.5 2þ
Follow-up MR grade
2þ
2þ
1þ
1þ
LVEF, %
60
45
20
50
15
Systolic PAP, mm Hg
30
38
42
32
60
NYHA functional class
II
II
II
I
IV/death during admission
*Device time: from transseptal puncture to deployment of the clip. IABP ¼ intra-aortic balloon pump; LV ¼ left ventricular; LVEF ¼ left ventricular ejection fraction; MI ¼ myocardial infarction; MR ¼ mitral regurgitation; MV ¼ mitral valve; NSTEMI ¼ non–ST-segment elevation myocardial infarction; NYHA ¼ New York Heart Association; PAP ¼ pulmonary artery pressure; STEMI ¼ ST-segment elevation myocardial infarction.
improvement at follow-up. These findings may help
http://dx.doi.org/10.1016/j.jacc.2015.03.597
to expand the clinical indications of this technology
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.
in more acute settings. *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 on behalf of the Spanish Working Group on MitraClip *Interventional Cardiology, Hospital de León Altos de Nava SN 24008 León Spain E-mail: [email protected]
REFERENCES 1. Nickenig G, Estevez-Loureiro R, Franzen O, et al. Percutaneous mitral valve edge-to-edge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011-2012 Pilot European Sentinel Registry. J Am Coll Cardiol 2014;64: 875–84. 2. Bilge M, Alemdar R, Yasar AS. Successful percutaneous mitral valve repair with the MitraClip system of acute mitral regurgitation due to papillary muscle rupture as complication of acute myocardial infarction. Catheter Cardiovasc Interv 2014;83:E137–40. 3. Chevalier P, Burri H, Fahrat F, et al. Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation. Eur J Cardiothorac Surg 2004;26:330–5. 4. Siegel RJ, Biner S, Rafique AM, et al. The acute hemodynamic effects of MitraClip therapy. J Am Coll Cardiol 2011;57:1658–65. 5. van Boven WJ, Gerritsen WB, Driessen AH, et al. Myocardial oxidative stress, and cell injury comparing three different techniques for coronary artery bypass grafting. Eur J Cardiothorac Surg 2008;34: 969–75.
