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• W2784386502 abstract "Mitral regurgitation commonly improves after implantation of a left ventricular assist device without concomitant valvular repair owing to the mechanical unloading of the left ventricle. However, the development (or persistence) of significant mitral regurgitation after implantation of a left ventricular assist device is associated with adverse clinical events. We present a case of a left ventricular assist device patient who successfully underwent a percutaneous MitraClip procedure for repair of persistent late postoperative mitral insufficiency with demonstrable clinical and hemodynamic improvement. Mitral regurgitation commonly improves after implantation of a left ventricular assist device without concomitant valvular repair owing to the mechanical unloading of the left ventricle. However, the development (or persistence) of significant mitral regurgitation after implantation of a left ventricular assist device is associated with adverse clinical events. We present a case of a left ventricular assist device patient who successfully underwent a percutaneous MitraClip procedure for repair of persistent late postoperative mitral insufficiency with demonstrable clinical and hemodynamic improvement. The MitraClip (Abbott, Abbott Park, IL) procedure is an established therapy for severe mitral insufficiency resulting from a primary valvular etiology. We describe use of the MitraClip system for treatment of symptomatic severe mitral insufficiency in a patient with a left ventricular assist device (LVAD), with the desired clinical result. Intraoperative transesophageal echocardiographic imaging was used in the standard fashion to guide deployment of the MitraClip system in this LVAD patient. A 57-year-old man with an ischemic cardiomyopathy (history of remote coronary artery bypass graft surgery after a large anterior myocardial infarction, with patent saphenonous vein to left anterior descending artery graft, patent saphenous vein to obtuse marginal artery graft, and occluded right internal thoracic artery to right coronary artery graft), left ventricular ejection fraction of 17%, mild aortic insufficiency (AI), and moderate mitral regurgitation (MR) underwent HeartMate II (Thoratec, Pleasanton, CA) LVAD implantation without concomitant valve procedures in May 2013. Postoperatively, the patient was clinically stable, but 2 years after the LVAD implantation, recurrent biventricular heart failure developed and was attributed to progression of MR and AI, with concomitant left ventricle dilation. The patient required several hospital admissions and was administered escalating doses of diuretics, including torsemide 100 mg twice daily as well as metolazone daily. Serial imaging over time with transthoracic echocardiography demonstrated mild-moderate AI progressing to moderate AI and worsening of moderate MR to severe MR. The etiology of MR was attributed to a degenerative leaflet pathology (Carpentier IIIb) with restriction of the posterior leaflet and an eccentric, posterior-directed jet of MR. In December 2016, the patient underwent the MitraClip procedure with deployment of a single clip across the P3A2 leaflets, with reduction in MR by transthoracic echocardiogram from 4+ to 1+. Before the procedure, the mitral valve (MV) annular diameter measured 3.9 cm, with MV area by planimetry of 4.1 cm2. The left ventricular end-diastolic dimension measured 5.5 cm and the left ventricular end-diastolic volume measured 144 mL. The long-axis of the left ventricle measured 7.1 cm, allowing adequate left ventricular geometry to deploy the MitraClip without significant risk of interference with the LVAD inflow cannula. After MitraClip deployment, the MV annular diameter measured 3.9 cm; left ventricular end-diastolic dimension measured 6.3 cm and left ventricular end-diastolic volume was 200.6 mL. The MV area was 3.9 cm2 measured by planimetry. The mean mitral gradient measured 2 mm Hg. Unfractionated heparin was used for intraprocedural anticoagulation therapy with an activated clotting time goal of 250 to 300. After the procedure, the patient did not receive anticoagulation therapy owing to a history of recurrent gastrointestinal bleeding. Diuretics were subsequently reduced to torsemide 50 mg twice daily without metolazone. On this regimen, he returned to New York Heart Association functional class I status and was discharged. One month later, right-side heart catheterization demonstrated marked hemodynamic improvement. Specifically, the pre-MitraClip right atrial pressure was reduced from 27 mm Hg to 8 mm Hg after MitraClip. Mean pulmonary artery pressure was reduced from 44 mm Hg to 23 mm Hg, and pulmonary capillary wedge pressure was reduced from 30 mm Hg to 12 mm Hg after intervention. Mean arterial pressure was 85 mm Hg by Doppler compared with 92 mm Hg after MitraClip. The LVAD flow was 5.3 L/min compared with 5.4 L/min after MitraClip. The forward cardiac output (cardiac index) as measured by thermodilution was 5.4 L/min (3.0 L · min−1 · m−2) before MitraClip compared with 3.6 L/min after (2.1 L · min−1 · m−2). Aortic insufficiency increased from mild to moderate in severity by echocardiography. To our knowledge, this is the first report of a percutaneous MitraClip procedure [1Feldman T. Kar S. Rinaldi M. et al.Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge Repair Study) cohort.J Am Coll Cardiol. 2009; 54: 686-694Crossref PubMed Scopus (756) Google Scholar] performed postoperatively in an LVAD recipient. After the procedure, the MR severity was significantly reduced, and both the clinical and hemodynamic profiles were dramatically improved. The patient’s diuretic regimen was reduced, and he has required no subsequent hospitalization for decompensated heart failure. The reductions in both right atrial and pulmonary artery pressures suggest MR was contributing to clinical right-side heart failure. In our case, compared with before the procedure, a decrease in resting thermodilution cardiac output was measured at the 1-month reassessment after the procedure. At that time, a marked decrease in pulmonary capillary wedge pressure was associated with increases in AI as assessed by echocardiography and quantitative central recirculation estimated by LVAD flow, exceeding thermodilution cardiac output. In general, numerous factors including valvular function, ventricular loading conditions, activation of the sympathetic nervous system, and level of sedation may affect cardiac output at the time of catheterization. Nevertheless, the improvement in MR permitted an overall marked improvement in hemodynamic and patient status. Whether to correct MR at the time of LVAD implant is debated [2Maltais S. Anwer L.A. The importance of mitral regurgitation in patients with left ventricular assist devices: an ongoing conundrum.J Am Coll Cardiol HF. 2017; 5: 89-91Google Scholar]. Significant MR after implantation of an LVAD may be associated with symptoms of pulmonary congestion, right ventricle dysfunction, and adverse clinical sequelae [3Kassis H. Cherukuri K. Agarwal R. et al.Significance of residual mitral regurgitation after continuous flow left ventricular assist device implantation.JACC Heart Fail. 2017; 5: 81-88Crossref PubMed Scopus (58) Google Scholar]. Significant postoperative residual MR is associated with higher pulmonary artery pressure and shorter times between LVAD implant to first hospitalization and death [3Kassis H. Cherukuri K. Agarwal R. et al.Significance of residual mitral regurgitation after continuous flow left ventricular assist device implantation.JACC Heart Fail. 2017; 5: 81-88Crossref PubMed Scopus (58) Google Scholar]. Furthermore, concomitant MV surgery can contribute to a reduction in pulmonary vascular resistance [4Taghavi S. Hamad E. Wilson L. et al.Mitral valve repair at the time of continuous-flow left ventricular assist device implantation confers meaningful decrement in pulmonary vascular resistance.ASAIO J. 2013; 59: 469-473Crossref PubMed Scopus (47) Google Scholar], which may have implications for candidacy for transplantation. Finally, in one reported series, improved hemodynamics and survival benefit of patients undergoing concomitant valve surgery at the time of LVAD implant was observed [5Tanaka A. Onsager D. Song T. et al.Surgically corrected mitral regurgitation during left ventricular assist device implantation is associated with low recurrence rate and improved midterm survival.Ann Thorac Surg. 2017; 103: 725-733Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Nonetheless, MR commonly improves without valvular repair after LVAD implantation, which is attributed to the acute mechanical unloading of the LV [6Goodwin M. Nemeh H.W. Borgi J. Paone G. Morgan J.A. Resolution of mitral regurgitation with left ventricular assist device support.Ann Thorac Surg. 2017; 104: 811-818Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. In our case, we postulate that chronic valve deterioration contributed to progressive valvular insufficiency involving both mitral and aortic valves. Registry and retrospective data have found that concomitant valve surgery at the time of LVAD implant may be associated with increases in early postsurgical adverse events (less than 30 days), incidence of early right-side heart failure, and need for right ventricular assist device [7Kirklin J.K. Naftel D.C. Pagani F.D. et al.Seventh INTERMACS annual report: 15,000 patients and counting.J Heart Lung Transplant. 2015; 34: 1495-1504Abstract Full Text Full Text PDF PubMed Scopus (1041) Google Scholar, 8John R. Naka Y. Park S.J. et al.Impact of concurrent surgical valve procedures in patients receiving continuous-flow devices.J Thorac Cardiovasc Surg. 2014; 147: 581-589Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar]. These findings are confounded, however, by valve surgery patients having higher preoperative risk profiles including older age, higher levels of blood urea nitrogen, central venous pressure/pulmonary capillary wedge pressure ratios, and decreased right ventricular stroke work indices [8John R. Naka Y. Park S.J. et al.Impact of concurrent surgical valve procedures in patients receiving continuous-flow devices.J Thorac Cardiovasc Surg. 2014; 147: 581-589Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar]. Our case illustrates an alternative for patients who do not undergo concomitant MV repair or who have significant MR late after LVAD implant. Delayed percutaneous MV intervention can be performed with the benefit of post-LVAD end-organ recovery and full left ventricular support. When severe preoperative MR is deemed to be due to primary MV pathology, concomitant repair at the time of LVAD implant may still be appropriate." @default.
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• W2784386502 title "Percutaneous Repair of Postoperative Mitral Regurgitation After Left Ventricular Assist Device Implant" @default.
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