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Utilization of intra-aortic balloon pump to allow MitraClip procedure in patients with non-coapting mitral valve leaflets: a case series

Utilization of intra-aortic balloon pump to allow MitraClip procedure in patients with... Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 CASE SERIES European Heart Journal - Case Reports (2019) 3, 1–7 doi:10.1093/ehjcr/ytz045 Heart failure Utilization of intra-aortic balloon pump to allow MitraClip procedure in patients with non-coapting mitral valve leaflets: a case series Ran Eliaz , Anna Turyan, Ronen Beeri, and Mony Shuvy* Heart Institute,Hadassah - Hebrew University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel Received 20 August 2018; accepted 4 April 2019; online publish-ahead-of-print 11 May 2019 Background The MitraClip (MC) procedure was designed for high-risk surgical patients with severe mitral regurgitation (MR). Some patients do not meet the required anatomical criteria due to advanced left ventricular remodelling and mitral annular dilatation leading to leaflet tethering and insufficient coaptation surface. Theoretically, ‘temporary remodel- ling’ of the mitral valve apparatus by pharmacological and/or mechanical support using intra-aortic balloon pump (IABP) could improve leaflets coaptation. ................................................................................................................................................................................................... Case summary We report a case series of four patients with severe MR and non-coapting leaflets who underwent MC implantation. Sufficient coaptation was achieved only after insertion of IABP. The first patient presented with worsening heart fail- ure and severe MR after a non-reperfused posterior wall myocardial infarction (MI), underwent a successful proced- ure with good results. The second patient presented with worsening heart failure secondary to rheumatic MR, and underwent MC procedure with good results after the insertion of IABP. The third patient developed worsening heart failure and severe MR 2 months after an acute inferior-lateral MI, and underwent a successful procedure. The fourth patient presented with respiratory failure, the patient underwent the procedure, but unfortunately died a few days following the procedure from multiorgan failure. In each case, the insertion of the IABP decreased annular mi- tral diameter and increased the coaptation surface as assessed by transoesophageal echocardiography. ................................................................................................................................................................................................... Discussion For patients suffering from symptomatic severe MR who are not suitable candidates for MC procedure, IABP sys- tem enabled us to overcome mitral leaflet gap and complete the MC procedure successfully. Keywords Case series Mitral regurgitation Edge-to-edge mitral valve repair MitraClip Intra-aortic balloon • • • • pump Learning points Intra-aortic balloon pump (IABP) insertion might allow MitraClip (MC) procedure in patients with non-coapting mitral valve leaflets. The use of IABP in dilated/functional mitral regurgitation might allow better leaflet coaptation via reduction in mitral annular diameter and increase in leaflet coaptation surface. Use of IABP to improve objective parameters, such as left ventricle geometry and mitral valve configuration, allows technically feasibility and success of MC procedure by better leaflet coaptation and optimization of MC procedure. * Corresponding author. Tel: 1972 2 677 6564, Fax: 1972 2 641 1028, Email: monysh@gmail.com Handling Editor: Nikolaos Bonaros Peer-reviewers: Marco De Carlo and Esther Cambronero-Cortinas Compliance Editor: Mohammed Majid Supplementary Material Editor: Peregrine Green V The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 2 R. Eliaz et al. Introduction Case presentation The MitraClip (MC) device (Abbott Laboratories, Abbott Park, IL, . Patient 1 USA) is a transvenous, edge-to-edge repair system for high-risk surgi- Patient information 1,2 cal patients with severe mitral regurgitation (MR). To guarantee A 69-year-old female patient with a prior history of hypertension, dia- the safe positioning of the MC, anatomical eligibility criteria are rec- betes, hyperlipidaemia, and ischaemic heart disease, who suffered a re- ommended: a coaptation length of valve leaflets > _2 mm, depth of cent non-reperfused posterior wall myocardial infarction (MI). <11 mm, and in the case of degenerative disease, a flail gap of Transthoracic echocardiography (TTE) showed mildly decreased LV <10 mm, and a flail width of <15 mm are favourable. A sufficient co- systolic function [LV ejection fraction (EF) 45–50%], moderately dilated aptation surface length is an important anatomical criterion, which left atrium, severe MR with apically tethered leaflets, other causes for precludes some patients from the procedure. decompensation, and murmur including ventricular septal defect Theoretically, the coaptation surface length might be altered by (VSD)/papillary muscle rupture, etc. were excluded. She continued suf- pharmacological or mechanical support. Intra-aortic balloon pump fering from congestive heart failure (CHF) symptoms: rest dyspnoea, (IABP) is the most widely used circulatory assist device in critically ill no physical capacity, diuretic dependence, and pulmonary congestion. patients with cardiac disease. Counterpulsation (i.e. balloon inflation in diastole and deflation in early systole) decreases pre- and afterload . Physical examination thus reducing myocardial oxygen consumption, left ventricle (LV) . On examination, she was with severe respiratory distress, her re- wall tension, and systolic pressure, and increasing diastolic pressure. spiratory rate was 30 breaths/min, and her lung examination was sug- These effects might allow a ‘temporary remodelling’ of the mitral gestive for pulmonary oedema, heart sounds were rapid and a harsh valve apparatus, which could improve coaptation. There are only pansystolic murmur was audible. few reports on the use of the IABP system in patients presenting in 6 . cardiogenic shock and require mitral valve intervention. . Interventions Nevertheless the use of IABP system for ‘non suitable’ anatomical . Although the patient was not an optimal candidate for MC and in this MR cases as means of allowing better leaflet coaptation is even more . . effort, an IABP was inserted and left in situ for 24 h in order to opti- limited. We have screened a cohort of 80 patients who underwent . . mize haemodynamic status, with the aim of altering LV geometry and MC implantation at the Hadassah Medical Center between August . to optimize the chances of success of MC by improving the coapta- 2015 and April 2018. Of these patients, we selected four patients tion length. On TOE, the baseline average annular diameter calcu- with non-coapting (i.e. ‘wide open’/‘free’) MR. In these patients, IABP lated in two orthogonal views, namely the mitral commissural (MC) was inserted prior to the MC procedure as a means of allowing bet- and long axis was 37 mm. The coaptation surface length calculated in ter leaflet coaptation as assessed by transoesophageal echocardiog- two orthogonal views was 3.9 mm. After insertion of IABP, the aver- raphy (TOE). age annular diameter decreased to 35 mm and the average coapta- tion surface length increased to 5.5 mm (Figure 1; Supplementary Timeline material online, Videos S1 and S2). Patient 1 6 January 2018: Inferior-posterior wall ST-elevation myocardial infarction (STEMI), underwent percutaneous coronary intervention (PCI) to left circumflex (LCX) artery, cardiogenic shock, pulmonary oedema, and intra-aortic balloon pump (IABP) insertion 7 January 2018: Transthoracic echocardiography (TTE) mildly dilated left ventricle (LV) with moderately reduced global systolic function, mod- erately dilated left atrium (LA), and mitral valve (MV): apical tethering of the leaflets causing incomplete closure and severe regurgitation. Moderately elevated pulmonary systolic pressure 50 mmHg. 31 January 2018: Patient discharged after weaning off IABP and optimal medical therapy for congestive heart failure (CHF) 10 February 2018: Admission for urinary tract infection, develops pulmonary oedema and worsening CHF 14 February 2018: TTE-dilated LV with moderate-severely reduced systolic function, severe mitral regurgitation (MR) with non-coapting MV leaflets 19 February 2018: IABP insertion 21 February 2018: MitraClip (MC) procedure after transoesophageal echocardiography (TOE) confirming severe MR with adequate coaptation surface 12 March 2018: CHF symptom improvement on oral medical therapy, discharged home 20 June 2018: Patient in New York Heart Association (NYHA) Class II and has not had any hospitalizations for heart failure. Mild MR on TTE Patient 2 27 March 2018: Admission for worsening CHF, pulmonary oedema, and rapidly conducted atrial fibrillation Continued Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 Utilization of IABP to allow MC procedure in patients with non-coapting MV leaflets 3 28 March 2018: TTE mildly dilated LV with preserved systolic function, moderately thickened MV leaflets, immobile posterior leaflet with dia- stolic doming of anterior leaflet suggesting rheumatic aetiology, severe regurgitation, severe tricuspid regurgitation, and severely elevated pul- monary systolic pressure (65 mmHg) 29 March 2018: TOE no left atrial appendage (LAA) thrombus and severe MR with small coaptation surface 1 April 2018: IABP insertion to allow better leaflet coaptation 3 April 2018: MC procedure under TOE guidance showing adequate leaflet coaptation 7 April 2018: Discharged home under oral medical therapy for CHF 22 April 2018: Patient in NYHA Class I and has not had any admission for heart failure. Mild-moderate MR on TTE Patient 3 17 September 2016: Posterior wall STEMI, undergoes PCI to LCX 18 September 2016: TTE moderate-severely dilated left ventricle with moderate-severely reduced global systolic function (ejection fraction 31%), moderate-severely dilated LA, moderately reduced right ventricle systolic function, mildly thickened MV leaflets with apical tethering causing incomplete closure and severe MR, and moderately elevated pulmonary systolic pressure 26 September 2016: Improvement of CHF symptoms under medical therapy, discharged home 30 September 2016: Readmitted for worsening CHF signs/symptoms and NSTEMI 10 October 2016: Undergoes PCI to right coronary artery with no improvement of CHF 31 October 2016: TOE severe/‘free’ MR, non-coaptating leaflets, and IABP is inserted 2 November 2016: Undergoes MC procedure after repeat TOE showing adequate coaptation surface 9 November 2016: Significant CHF signs/symptoms improvement, discharged home 10 March 2017: Patient in NYHA Class II has had only one hospitalization for worsening CHF. TTE showed mild-moderate MR Patient 4 24 December 2017: Admission for worsening CHF and pneumonia needing mechanical ventilation 24 December 2017: TTE normal size left ventricle with normal global systolic function, severely dilated LA, normal size right ventricle with nor- mal systolic function, mitral annular calcification, mildly thickened MV leaflets, restricted motion of the posterior leaflet causing severe regur- gitation, moderate-severe TR, and moderate-severely elevated pulmonary systolic pressure 20 January 2017: Slight improvement in CHF signs/symptoms, failure to wean from ventilator, and undergoes tracheotomy 28 January 2017: Develops ventilator associated pneumonia and septic shock 28 February 2017: TTE mildly dilated LV with mild-moderately reduced systolic function, severe MR, and severe pulmonary hypertension 2 March 2017: Undergoes IABP insertion 4 March 2017: Undergoes successful MC procedure after repeat TOE showing better leaflet coaptation surface 9 March 2017: Develops multiorgan failure and dies She underwent the procedure with no major complications. Two Physical examination On examination, she was in respiratory distress, her respiratory rate clips were implanted with a decrease of MR grade from þ4to þ2 and no evidence of mitral stenosis. was 30 breaths/min, and her oxygen saturation was 86%. She had a clearly audible pansystolic murmur, and her lung examination was . suggestive for pulmonary oedema. Follow-up and outcomes The IABP was removed 12 h following the procedure after assuring stable clinical and euvolemic status. The patient was discharged few . days later in good condition, with no additional episodes of pulmon- . Interventions ary oedema. Three months after discharge, the patient was stable Transoesophageal echocardiography showed severe MR with prac- at New York Heart Association (NYHA) functional Class II. tically non-coapting leaflets. An IABP was inserted 24 h prior to the Transthoracic echocardiography showed only mild MR with border- procedure when the patient was euvolemic after diuretic therapy, line LV systolic function (EF 50%). . with the aim of altering LV geometry to optimize the chances of suc- . cess of MC by improving leaflet coaptation surface length and annular Patient 2 diameter. Baseline average annular diameter on TOE was 48 mm and the average coaptation surface length was 1.8 mm. After insertion of Patient information An 80-year-old female patient with a prior history of hypertension, IABP, the average annular diameter decreased to 39 mm and the chronic hepatitis C carrier, paroxysmal atrial fibrillation, cerebrovas- average coaptation surface length increased to 5.2 mm. Three mitral cular accident, and rheumatic heart disease with known severe MR. . clips were implanted reducing MR severity from severe to mild- She was admitted to the cardiac intensive care unit due to pulmonary . moderate and atrial V-wave from 60 to 25 mmHg (Figure 2; congestion. Supplementary material online, Videos S5–S7). Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 4 R. Eliaz et al. Figure 1 Average annular diameter and coaptation surface length before and after insertion of intra-aortic balloon pump in Patient 1. Follow-up and outcomes and to achieve LV geometry alteration thus allowing better leaflet co- The IABP was removed 24 h following the MC procedure after assur- aptation to optimize MC success. Mitral valve measurements using ing stable haemodynamic and euvolemic status. The patient was dis- TOE showed an average annular diameter of 42 mm, and coaptation charged a few days later in good condition, with no additional . surface length of 1.9 mm. After insertion of IABP, the average annular episodes of pulmonary oedema. Three months after discharge, the . diameter was 34 mm and the average coaptation surface length was patient was stable at NYHA functional Class I. Follow-up TTE . 4.4 mm (Figure 3); see Supplementary material online, Videos S3 and showed mild-moderate MR and mild-moderate LV systolic function S4). The patient underwent implantation of three MCs, with a good (EF 45%). overall results and improvement of the MR from severe to mild- moderate. Patient 3 Patient information . Follow-up and outcomes A 74-year-old female patient with a prior history of hypertension, . Following the MC procedure for 48 h, the patient was weaned from hyperlipidaemia, diabetes, asthma, chronic renal failure, and ischaemic . the IABP after assuring stable haemodynamic status. The patient was heart disease. Two months prior to her admission, she was treated in discharged a few days later in good condition, with major improve- the cardiac intensive care unit for inferior-lateral ST-elevation myo- ment in NYHA symptoms and no additional episodes of pulmonary cardial infarction and underwent percutaneous coronary interven- oedema. Three months after discharge, the patient was stable at tion (PCI) to the left circumflex (LCX) artery. NYHA Class II. Follow-up TTE showed moderate MR with moder- ately reduced LV function (EF 40%). Physical examination On examination, she was in respiratory distress (25 breaths/min) and Patient 4 her oxygen saturation was 86% on room air. Upon auscultation, she Patient information had a clear audible systolic murmur radiating to her left axilla, had An 80-year-old female patient with a prior history of hypertension, diminished lung sounds in the bases and crackles suggestive for pul- hyperlipidaemia, diabetes, and ischaemic heart disease with a prior in- monary oedema. . ferior MI and PCI with drug-eluting stent placement to LCX, 3 years . prior to her current admission. She was admitted with respiratory Interventions failure due to pulmonary oedema and pneumonia. The patient did not improve despite maximal medical therapy and remained in NYHA Classes III–IV. Transoesophageal echocardi- Physical examination ography showed severe MR with practically no leaflet coaptation The patient was conscious, intubated, and ventilated with remarkable (‘Free MR’), and other causes for severe MR (VSD/papillary muscle . tachypnoea, her blood pressure was 80/50 mmHg and her pulse 100 rupture, etc.) were excluded. Prior to the procedure an IABP was . b.p.m. There were decreased lung sound in both bases, heart sounds placed for 48 h to help maintain clinical stability and euvolemic status, were irregular and fast, periphery was cold and dry. Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 Utilization of IABP to allow MC procedure in patients with non-coapting MV leaflets 5 Figure 2 (A, B) Transoesophageal echocardiography long-axis view with and without colour Doppler before intra-aortic balloon pump, with and without colour Doppler after intra-aortic balloon pump and after MitraClip. Figure 3 Average annular diameter and coaptation surface length before and after insertion of intra-aortic balloon pump in Patient 2. Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 6 R. Eliaz et al. Figure 4 Average mitral annuls diameter and coaptation surface in study patients. All measurements were obtained prior and after the insertion of intra-aortic balloon pump and the values were compared using the paired Student’s t-test. Interventions regurgitation that arises from the commissures is particularly difficult to treat with MC. Similarly, large flail segments with an excess of co- Initial TTE upon admission showed normal size LV with normal global aptation gap have a high failure rate with MC therapy. systolic function, severe ischaemic MR (posteriorly directed wall jet), In our experience, treating this unique and complex sub- and no stenosis. After a 10-day period with improvement of infec- population of patients suffering from severe symptomatic MR, based tious status, but no improvement in her CHF signs and inability to . on current accepted criteria, both echocardiographic and anatomical, wean from mechanical ventilation due to continuous pulmonary con- . were not suitable candidates for MC procedure. Using the aid of gestion, a decision was made to perform urgent mitral clipping as sal- . IABP system enabled us to overcome mitral leaflet gap and complete vage therapy. Prior to the procedure, TOE was performed that . the procedure of MC uneventfully. In all cases, IABP insertion showed severe MR with a posteriorly directed jet, severe malcoapta- resulted in a 2–9 mm decrease in mean annular diameter and an in- tion mainly resulting from posterior leaflet immobility, and no evi- . crease of 1.6–3.4 mm average in coaptation surface allowing per- dence of papillary muscle rupture or new VSD. Mitral valve . formance of the MC (Figure 4). The beneficial effects of IABP were measurements were based on TOE prior to the procedure: average . noted immediately after its insertion, reducing afterload, and change annular diameter was 40 mm and average coaptation surface length . in LV geometry and valvular apparatus. This in turn led to better leaf- was 2.9 mm. An IABP was inserted 3 days prior to the procedure as . let coaptation via reduction in annular diameter, increase in coapta- means of haemodynamic support and aim of altering LV geometry to tion surface, and allowing better mitral leaflet grasping and durable optimize the chances of success of MC by improving leaflet coapta- . result in terms of MR reduction and avoidance of mitral valve sten- tion surface length and annular diameter. Transoesophageal . osis. This feature of the IABP and its effect on LV highlights its import- echocardiography after insertion of IABP showed an average annular . ant role in the immediate procedural phase and overall procedural diameter of 36 mm and average coaptation surface length was 5.2 . success in this unique and very complicated patient population. mm. Two MCs were implanted (one medially and one laterally to the . This indicates that the effects of the IABP on procedural success prominent calcification). Mitral regurgitation improved from severe . could be explained both by the pure haemodynamic effect on LV via to moderate and atrial V-wave decreased from 60 to 25 mmHg, with unloading and afterload reduction, and also via a direct action on mi- no immediate post-procedural complications. tral valve anatomy and physiology, by allowing leaflet coaptation irre- spective to LV function. Importantly, had there been no Follow-up and outcomes improvement in the patient haemodynamic and mitral valve parame- Following the procedure there was an initial improvement in in . ters the decision to go forth with the MC procedure would have her respiratory condition, the IABP was kept in situ to allow bet- . . been on a case by case basis. In a few other cases, we have tried to ter haemodynamic and vulemic support. Unfortunately 7 days . . perform MC procedure using IABP albeit failing to improve LV and after the procedure, she developed ventilator associated pneumo- . . mitral valve leaflet dimensions unfortunately with poor results. This nia and sepsis with multiorgan failure, she died 10 days following . . fact outlines the importance of patient selection combined with the the procedure. . use of IABP to allow a successful MC procedure. Technical procedural decisions as to the number of clips implanted (between 2 and 3) in each patient was dependent on the coaptation Discussion . surface defect and the amount of MR. As a result, some patients The specific anatomy best suited for MC therapy includes a relatively needed two clips to achieve significant MR reduction without causing central MR jet origin and a coaptation gap of <15 mm. Mitral MS and in others three clips were needed to achieve a durable result Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 Utilization of IABP to allow MC procedure in patients with non-coapting MV leaflets 7 without causing significant MS. This is in line with current practice Slide sets: A fully edited slide set detailing this case and suitable for methods in the treatment of severe MR. local presentation is available online as Supplementary data. Thus, we recommend expanding the indications and use of IABP . Consent: The author/s confirm that written consent for submis- to both patient populations, allowing then to benefit from percutan- sion and publication of this case report including image(s) and eous mitral valve repair via MC. associated text has been obtained from the patient in line with COPE guidance. Conclusion . Conflict of interest: none declared. We presented four patients with heart failure and severe MR and non-coaptating valve leaflets. In each case we succeeded in achieving References better leaflet coaptation by inserting IABP allowing an MC procedure 1. Feldman T, Wasserman HS, Herrmann HC, Gray W, Block PC, Whitlow P, St in an otherwise unsuitable/precluded case. Goar F, Rodriguez L, Silvestry F, Schwartz A, Sanborn TA, Condado JA, Foster E. Percutaneous mitral valve repair using the edge-to-edge technique: six-month results of the EVEREST phase I clinical trial. J Am Coll Cardiol 2005;46:2134–2140. Lead author biography . 2. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baro ´ n-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Dr Ran Eliaz began his medical training at . Pierard L, Price S, Scha ¨fers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M. Guidelines on the man- the Semmelweis University from which he agement of valvular heart disease. Eur Heart J 2012;33:2451–2496. graduated with honour at 2008. He then 3. Feldman T, Kar S, Rinaldi M, Fail P, Hermiller J, Smalling R, Whitlow PL, Gray W, Low continued his practical training in the field of . R, Herrmann HC, Lim S, Foster E, Glower D. Percutaneous mitral repair with the MitraClip system. Safety and midterm durability in the initial EVEREST (Endovascular Internal medicine and Cardiology at the . . Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol 2009;54:686–694. Hadassah university hospital in Jerusalem be- . 4. Krishna M, Zacharowski K. Principles of intra-aortic balloon pump counterpulsa- tween the years 2009 and 2018. He is cur- . tion. Cont Edu Anaesth Crit Care Pain 2009;9:24–28. 5. Buckert D, Markovic S, Kunze M, Wo ¨ hrle J, Rottbauer W, Walcher D. rently working as an academic and . TM . Percutaneous mitral valve repair with the MitraClip NT system in a patient pre- interventional cardiology fellow at the Heart . senting with prolonged cardiogenic shock. Clin Case Rep 2017;5:1807–1810. Institute Hadassah Medical Center. . 6. Melisurgo G, Ajello S, Pappalardo F, Guidotti A, Agricola E, Kawaguchi M, Latib A, Covello RD, Denti P, Zangrillo A, Alfieri O, Maisano F. Afterload mismatch after Mitraclip insertion for functional mitral regurgitation. Am J Cardiol 2014;113: 1844–1850. Supplementary material . . 7. Biner S, Perk G, Kar S, Rafique AM, Slater J, Shiota T, Hussaini A, Chou S, Kronzon I, Siegel RJ. Utility of combined two-dimensional and three-dimensional Supplementary material is available at European Heart Journal - Case . transesophageal imaging for catheter-based mitral valve clip repair of mitral regur- Reports online. . gitation. J Am Soc Echocardiogr 2011;24:611–617. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Utilization of intra-aortic balloon pump to allow MitraClip procedure in patients with non-coapting mitral valve leaflets: a case series

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Oxford University Press
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© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.
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2514-2119
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10.1093/ehjcr/ytz045
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Abstract

Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 CASE SERIES European Heart Journal - Case Reports (2019) 3, 1–7 doi:10.1093/ehjcr/ytz045 Heart failure Utilization of intra-aortic balloon pump to allow MitraClip procedure in patients with non-coapting mitral valve leaflets: a case series Ran Eliaz , Anna Turyan, Ronen Beeri, and Mony Shuvy* Heart Institute,Hadassah - Hebrew University Medical Center, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel Received 20 August 2018; accepted 4 April 2019; online publish-ahead-of-print 11 May 2019 Background The MitraClip (MC) procedure was designed for high-risk surgical patients with severe mitral regurgitation (MR). Some patients do not meet the required anatomical criteria due to advanced left ventricular remodelling and mitral annular dilatation leading to leaflet tethering and insufficient coaptation surface. Theoretically, ‘temporary remodel- ling’ of the mitral valve apparatus by pharmacological and/or mechanical support using intra-aortic balloon pump (IABP) could improve leaflets coaptation. ................................................................................................................................................................................................... Case summary We report a case series of four patients with severe MR and non-coapting leaflets who underwent MC implantation. Sufficient coaptation was achieved only after insertion of IABP. The first patient presented with worsening heart fail- ure and severe MR after a non-reperfused posterior wall myocardial infarction (MI), underwent a successful proced- ure with good results. The second patient presented with worsening heart failure secondary to rheumatic MR, and underwent MC procedure with good results after the insertion of IABP. The third patient developed worsening heart failure and severe MR 2 months after an acute inferior-lateral MI, and underwent a successful procedure. The fourth patient presented with respiratory failure, the patient underwent the procedure, but unfortunately died a few days following the procedure from multiorgan failure. In each case, the insertion of the IABP decreased annular mi- tral diameter and increased the coaptation surface as assessed by transoesophageal echocardiography. ................................................................................................................................................................................................... Discussion For patients suffering from symptomatic severe MR who are not suitable candidates for MC procedure, IABP sys- tem enabled us to overcome mitral leaflet gap and complete the MC procedure successfully. Keywords Case series Mitral regurgitation Edge-to-edge mitral valve repair MitraClip Intra-aortic balloon • • • • pump Learning points Intra-aortic balloon pump (IABP) insertion might allow MitraClip (MC) procedure in patients with non-coapting mitral valve leaflets. The use of IABP in dilated/functional mitral regurgitation might allow better leaflet coaptation via reduction in mitral annular diameter and increase in leaflet coaptation surface. Use of IABP to improve objective parameters, such as left ventricle geometry and mitral valve configuration, allows technically feasibility and success of MC procedure by better leaflet coaptation and optimization of MC procedure. * Corresponding author. Tel: 1972 2 677 6564, Fax: 1972 2 641 1028, Email: monysh@gmail.com Handling Editor: Nikolaos Bonaros Peer-reviewers: Marco De Carlo and Esther Cambronero-Cortinas Compliance Editor: Mohammed Majid Supplementary Material Editor: Peregrine Green V The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 2 R. Eliaz et al. Introduction Case presentation The MitraClip (MC) device (Abbott Laboratories, Abbott Park, IL, . Patient 1 USA) is a transvenous, edge-to-edge repair system for high-risk surgi- Patient information 1,2 cal patients with severe mitral regurgitation (MR). To guarantee A 69-year-old female patient with a prior history of hypertension, dia- the safe positioning of the MC, anatomical eligibility criteria are rec- betes, hyperlipidaemia, and ischaemic heart disease, who suffered a re- ommended: a coaptation length of valve leaflets > _2 mm, depth of cent non-reperfused posterior wall myocardial infarction (MI). <11 mm, and in the case of degenerative disease, a flail gap of Transthoracic echocardiography (TTE) showed mildly decreased LV <10 mm, and a flail width of <15 mm are favourable. A sufficient co- systolic function [LV ejection fraction (EF) 45–50%], moderately dilated aptation surface length is an important anatomical criterion, which left atrium, severe MR with apically tethered leaflets, other causes for precludes some patients from the procedure. decompensation, and murmur including ventricular septal defect Theoretically, the coaptation surface length might be altered by (VSD)/papillary muscle rupture, etc. were excluded. She continued suf- pharmacological or mechanical support. Intra-aortic balloon pump fering from congestive heart failure (CHF) symptoms: rest dyspnoea, (IABP) is the most widely used circulatory assist device in critically ill no physical capacity, diuretic dependence, and pulmonary congestion. patients with cardiac disease. Counterpulsation (i.e. balloon inflation in diastole and deflation in early systole) decreases pre- and afterload . Physical examination thus reducing myocardial oxygen consumption, left ventricle (LV) . On examination, she was with severe respiratory distress, her re- wall tension, and systolic pressure, and increasing diastolic pressure. spiratory rate was 30 breaths/min, and her lung examination was sug- These effects might allow a ‘temporary remodelling’ of the mitral gestive for pulmonary oedema, heart sounds were rapid and a harsh valve apparatus, which could improve coaptation. There are only pansystolic murmur was audible. few reports on the use of the IABP system in patients presenting in 6 . cardiogenic shock and require mitral valve intervention. . Interventions Nevertheless the use of IABP system for ‘non suitable’ anatomical . Although the patient was not an optimal candidate for MC and in this MR cases as means of allowing better leaflet coaptation is even more . . effort, an IABP was inserted and left in situ for 24 h in order to opti- limited. We have screened a cohort of 80 patients who underwent . . mize haemodynamic status, with the aim of altering LV geometry and MC implantation at the Hadassah Medical Center between August . to optimize the chances of success of MC by improving the coapta- 2015 and April 2018. Of these patients, we selected four patients tion length. On TOE, the baseline average annular diameter calcu- with non-coapting (i.e. ‘wide open’/‘free’) MR. In these patients, IABP lated in two orthogonal views, namely the mitral commissural (MC) was inserted prior to the MC procedure as a means of allowing bet- and long axis was 37 mm. The coaptation surface length calculated in ter leaflet coaptation as assessed by transoesophageal echocardiog- two orthogonal views was 3.9 mm. After insertion of IABP, the aver- raphy (TOE). age annular diameter decreased to 35 mm and the average coapta- tion surface length increased to 5.5 mm (Figure 1; Supplementary Timeline material online, Videos S1 and S2). Patient 1 6 January 2018: Inferior-posterior wall ST-elevation myocardial infarction (STEMI), underwent percutaneous coronary intervention (PCI) to left circumflex (LCX) artery, cardiogenic shock, pulmonary oedema, and intra-aortic balloon pump (IABP) insertion 7 January 2018: Transthoracic echocardiography (TTE) mildly dilated left ventricle (LV) with moderately reduced global systolic function, mod- erately dilated left atrium (LA), and mitral valve (MV): apical tethering of the leaflets causing incomplete closure and severe regurgitation. Moderately elevated pulmonary systolic pressure 50 mmHg. 31 January 2018: Patient discharged after weaning off IABP and optimal medical therapy for congestive heart failure (CHF) 10 February 2018: Admission for urinary tract infection, develops pulmonary oedema and worsening CHF 14 February 2018: TTE-dilated LV with moderate-severely reduced systolic function, severe mitral regurgitation (MR) with non-coapting MV leaflets 19 February 2018: IABP insertion 21 February 2018: MitraClip (MC) procedure after transoesophageal echocardiography (TOE) confirming severe MR with adequate coaptation surface 12 March 2018: CHF symptom improvement on oral medical therapy, discharged home 20 June 2018: Patient in New York Heart Association (NYHA) Class II and has not had any hospitalizations for heart failure. Mild MR on TTE Patient 2 27 March 2018: Admission for worsening CHF, pulmonary oedema, and rapidly conducted atrial fibrillation Continued Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 Utilization of IABP to allow MC procedure in patients with non-coapting MV leaflets 3 28 March 2018: TTE mildly dilated LV with preserved systolic function, moderately thickened MV leaflets, immobile posterior leaflet with dia- stolic doming of anterior leaflet suggesting rheumatic aetiology, severe regurgitation, severe tricuspid regurgitation, and severely elevated pul- monary systolic pressure (65 mmHg) 29 March 2018: TOE no left atrial appendage (LAA) thrombus and severe MR with small coaptation surface 1 April 2018: IABP insertion to allow better leaflet coaptation 3 April 2018: MC procedure under TOE guidance showing adequate leaflet coaptation 7 April 2018: Discharged home under oral medical therapy for CHF 22 April 2018: Patient in NYHA Class I and has not had any admission for heart failure. Mild-moderate MR on TTE Patient 3 17 September 2016: Posterior wall STEMI, undergoes PCI to LCX 18 September 2016: TTE moderate-severely dilated left ventricle with moderate-severely reduced global systolic function (ejection fraction 31%), moderate-severely dilated LA, moderately reduced right ventricle systolic function, mildly thickened MV leaflets with apical tethering causing incomplete closure and severe MR, and moderately elevated pulmonary systolic pressure 26 September 2016: Improvement of CHF symptoms under medical therapy, discharged home 30 September 2016: Readmitted for worsening CHF signs/symptoms and NSTEMI 10 October 2016: Undergoes PCI to right coronary artery with no improvement of CHF 31 October 2016: TOE severe/‘free’ MR, non-coaptating leaflets, and IABP is inserted 2 November 2016: Undergoes MC procedure after repeat TOE showing adequate coaptation surface 9 November 2016: Significant CHF signs/symptoms improvement, discharged home 10 March 2017: Patient in NYHA Class II has had only one hospitalization for worsening CHF. TTE showed mild-moderate MR Patient 4 24 December 2017: Admission for worsening CHF and pneumonia needing mechanical ventilation 24 December 2017: TTE normal size left ventricle with normal global systolic function, severely dilated LA, normal size right ventricle with nor- mal systolic function, mitral annular calcification, mildly thickened MV leaflets, restricted motion of the posterior leaflet causing severe regur- gitation, moderate-severe TR, and moderate-severely elevated pulmonary systolic pressure 20 January 2017: Slight improvement in CHF signs/symptoms, failure to wean from ventilator, and undergoes tracheotomy 28 January 2017: Develops ventilator associated pneumonia and septic shock 28 February 2017: TTE mildly dilated LV with mild-moderately reduced systolic function, severe MR, and severe pulmonary hypertension 2 March 2017: Undergoes IABP insertion 4 March 2017: Undergoes successful MC procedure after repeat TOE showing better leaflet coaptation surface 9 March 2017: Develops multiorgan failure and dies She underwent the procedure with no major complications. Two Physical examination On examination, she was in respiratory distress, her respiratory rate clips were implanted with a decrease of MR grade from þ4to þ2 and no evidence of mitral stenosis. was 30 breaths/min, and her oxygen saturation was 86%. She had a clearly audible pansystolic murmur, and her lung examination was . suggestive for pulmonary oedema. Follow-up and outcomes The IABP was removed 12 h following the procedure after assuring stable clinical and euvolemic status. The patient was discharged few . days later in good condition, with no additional episodes of pulmon- . Interventions ary oedema. Three months after discharge, the patient was stable Transoesophageal echocardiography showed severe MR with prac- at New York Heart Association (NYHA) functional Class II. tically non-coapting leaflets. An IABP was inserted 24 h prior to the Transthoracic echocardiography showed only mild MR with border- procedure when the patient was euvolemic after diuretic therapy, line LV systolic function (EF 50%). . with the aim of altering LV geometry to optimize the chances of suc- . cess of MC by improving leaflet coaptation surface length and annular Patient 2 diameter. Baseline average annular diameter on TOE was 48 mm and the average coaptation surface length was 1.8 mm. After insertion of Patient information An 80-year-old female patient with a prior history of hypertension, IABP, the average annular diameter decreased to 39 mm and the chronic hepatitis C carrier, paroxysmal atrial fibrillation, cerebrovas- average coaptation surface length increased to 5.2 mm. Three mitral cular accident, and rheumatic heart disease with known severe MR. . clips were implanted reducing MR severity from severe to mild- She was admitted to the cardiac intensive care unit due to pulmonary . moderate and atrial V-wave from 60 to 25 mmHg (Figure 2; congestion. Supplementary material online, Videos S5–S7). Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 4 R. Eliaz et al. Figure 1 Average annular diameter and coaptation surface length before and after insertion of intra-aortic balloon pump in Patient 1. Follow-up and outcomes and to achieve LV geometry alteration thus allowing better leaflet co- The IABP was removed 24 h following the MC procedure after assur- aptation to optimize MC success. Mitral valve measurements using ing stable haemodynamic and euvolemic status. The patient was dis- TOE showed an average annular diameter of 42 mm, and coaptation charged a few days later in good condition, with no additional . surface length of 1.9 mm. After insertion of IABP, the average annular episodes of pulmonary oedema. Three months after discharge, the . diameter was 34 mm and the average coaptation surface length was patient was stable at NYHA functional Class I. Follow-up TTE . 4.4 mm (Figure 3); see Supplementary material online, Videos S3 and showed mild-moderate MR and mild-moderate LV systolic function S4). The patient underwent implantation of three MCs, with a good (EF 45%). overall results and improvement of the MR from severe to mild- moderate. Patient 3 Patient information . Follow-up and outcomes A 74-year-old female patient with a prior history of hypertension, . Following the MC procedure for 48 h, the patient was weaned from hyperlipidaemia, diabetes, asthma, chronic renal failure, and ischaemic . the IABP after assuring stable haemodynamic status. The patient was heart disease. Two months prior to her admission, she was treated in discharged a few days later in good condition, with major improve- the cardiac intensive care unit for inferior-lateral ST-elevation myo- ment in NYHA symptoms and no additional episodes of pulmonary cardial infarction and underwent percutaneous coronary interven- oedema. Three months after discharge, the patient was stable at tion (PCI) to the left circumflex (LCX) artery. NYHA Class II. Follow-up TTE showed moderate MR with moder- ately reduced LV function (EF 40%). Physical examination On examination, she was in respiratory distress (25 breaths/min) and Patient 4 her oxygen saturation was 86% on room air. Upon auscultation, she Patient information had a clear audible systolic murmur radiating to her left axilla, had An 80-year-old female patient with a prior history of hypertension, diminished lung sounds in the bases and crackles suggestive for pul- hyperlipidaemia, diabetes, and ischaemic heart disease with a prior in- monary oedema. . ferior MI and PCI with drug-eluting stent placement to LCX, 3 years . prior to her current admission. She was admitted with respiratory Interventions failure due to pulmonary oedema and pneumonia. The patient did not improve despite maximal medical therapy and remained in NYHA Classes III–IV. Transoesophageal echocardi- Physical examination ography showed severe MR with practically no leaflet coaptation The patient was conscious, intubated, and ventilated with remarkable (‘Free MR’), and other causes for severe MR (VSD/papillary muscle . tachypnoea, her blood pressure was 80/50 mmHg and her pulse 100 rupture, etc.) were excluded. Prior to the procedure an IABP was . b.p.m. There were decreased lung sound in both bases, heart sounds placed for 48 h to help maintain clinical stability and euvolemic status, were irregular and fast, periphery was cold and dry. Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 Utilization of IABP to allow MC procedure in patients with non-coapting MV leaflets 5 Figure 2 (A, B) Transoesophageal echocardiography long-axis view with and without colour Doppler before intra-aortic balloon pump, with and without colour Doppler after intra-aortic balloon pump and after MitraClip. Figure 3 Average annular diameter and coaptation surface length before and after insertion of intra-aortic balloon pump in Patient 2. Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 6 R. Eliaz et al. Figure 4 Average mitral annuls diameter and coaptation surface in study patients. All measurements were obtained prior and after the insertion of intra-aortic balloon pump and the values were compared using the paired Student’s t-test. Interventions regurgitation that arises from the commissures is particularly difficult to treat with MC. Similarly, large flail segments with an excess of co- Initial TTE upon admission showed normal size LV with normal global aptation gap have a high failure rate with MC therapy. systolic function, severe ischaemic MR (posteriorly directed wall jet), In our experience, treating this unique and complex sub- and no stenosis. After a 10-day period with improvement of infec- population of patients suffering from severe symptomatic MR, based tious status, but no improvement in her CHF signs and inability to . on current accepted criteria, both echocardiographic and anatomical, wean from mechanical ventilation due to continuous pulmonary con- . were not suitable candidates for MC procedure. Using the aid of gestion, a decision was made to perform urgent mitral clipping as sal- . IABP system enabled us to overcome mitral leaflet gap and complete vage therapy. Prior to the procedure, TOE was performed that . the procedure of MC uneventfully. In all cases, IABP insertion showed severe MR with a posteriorly directed jet, severe malcoapta- resulted in a 2–9 mm decrease in mean annular diameter and an in- tion mainly resulting from posterior leaflet immobility, and no evi- . crease of 1.6–3.4 mm average in coaptation surface allowing per- dence of papillary muscle rupture or new VSD. Mitral valve . formance of the MC (Figure 4). The beneficial effects of IABP were measurements were based on TOE prior to the procedure: average . noted immediately after its insertion, reducing afterload, and change annular diameter was 40 mm and average coaptation surface length . in LV geometry and valvular apparatus. This in turn led to better leaf- was 2.9 mm. An IABP was inserted 3 days prior to the procedure as . let coaptation via reduction in annular diameter, increase in coapta- means of haemodynamic support and aim of altering LV geometry to tion surface, and allowing better mitral leaflet grasping and durable optimize the chances of success of MC by improving leaflet coapta- . result in terms of MR reduction and avoidance of mitral valve sten- tion surface length and annular diameter. Transoesophageal . osis. This feature of the IABP and its effect on LV highlights its import- echocardiography after insertion of IABP showed an average annular . ant role in the immediate procedural phase and overall procedural diameter of 36 mm and average coaptation surface length was 5.2 . success in this unique and very complicated patient population. mm. Two MCs were implanted (one medially and one laterally to the . This indicates that the effects of the IABP on procedural success prominent calcification). Mitral regurgitation improved from severe . could be explained both by the pure haemodynamic effect on LV via to moderate and atrial V-wave decreased from 60 to 25 mmHg, with unloading and afterload reduction, and also via a direct action on mi- no immediate post-procedural complications. tral valve anatomy and physiology, by allowing leaflet coaptation irre- spective to LV function. Importantly, had there been no Follow-up and outcomes improvement in the patient haemodynamic and mitral valve parame- Following the procedure there was an initial improvement in in . ters the decision to go forth with the MC procedure would have her respiratory condition, the IABP was kept in situ to allow bet- . . been on a case by case basis. In a few other cases, we have tried to ter haemodynamic and vulemic support. Unfortunately 7 days . . perform MC procedure using IABP albeit failing to improve LV and after the procedure, she developed ventilator associated pneumo- . . mitral valve leaflet dimensions unfortunately with poor results. This nia and sepsis with multiorgan failure, she died 10 days following . . fact outlines the importance of patient selection combined with the the procedure. . use of IABP to allow a successful MC procedure. Technical procedural decisions as to the number of clips implanted (between 2 and 3) in each patient was dependent on the coaptation Discussion . surface defect and the amount of MR. As a result, some patients The specific anatomy best suited for MC therapy includes a relatively needed two clips to achieve significant MR reduction without causing central MR jet origin and a coaptation gap of <15 mm. Mitral MS and in others three clips were needed to achieve a durable result Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/2/ytz045/5488151 by Ed 'DeepDyve' Gillespie user on 02 July 2019 Utilization of IABP to allow MC procedure in patients with non-coapting MV leaflets 7 without causing significant MS. This is in line with current practice Slide sets: A fully edited slide set detailing this case and suitable for methods in the treatment of severe MR. local presentation is available online as Supplementary data. Thus, we recommend expanding the indications and use of IABP . Consent: The author/s confirm that written consent for submis- to both patient populations, allowing then to benefit from percutan- sion and publication of this case report including image(s) and eous mitral valve repair via MC. associated text has been obtained from the patient in line with COPE guidance. Conclusion . Conflict of interest: none declared. We presented four patients with heart failure and severe MR and non-coaptating valve leaflets. In each case we succeeded in achieving References better leaflet coaptation by inserting IABP allowing an MC procedure 1. Feldman T, Wasserman HS, Herrmann HC, Gray W, Block PC, Whitlow P, St in an otherwise unsuitable/precluded case. Goar F, Rodriguez L, Silvestry F, Schwartz A, Sanborn TA, Condado JA, Foster E. Percutaneous mitral valve repair using the edge-to-edge technique: six-month results of the EVEREST phase I clinical trial. J Am Coll Cardiol 2005;46:2134–2140. Lead author biography . 2. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baro ´ n-Esquivias G, Baumgartner H, Borger MA, Carrel TP, De Bonis M, Evangelista A, Falk V, Iung B, Lancellotti P, Dr Ran Eliaz began his medical training at . Pierard L, Price S, Scha ¨fers HJ, Schuler G, Stepinska J, Swedberg K, Takkenberg J, Von Oppell UO, Windecker S, Zamorano JL, Zembala M. Guidelines on the man- the Semmelweis University from which he agement of valvular heart disease. Eur Heart J 2012;33:2451–2496. graduated with honour at 2008. He then 3. Feldman T, Kar S, Rinaldi M, Fail P, Hermiller J, Smalling R, Whitlow PL, Gray W, Low continued his practical training in the field of . R, Herrmann HC, Lim S, Foster E, Glower D. Percutaneous mitral repair with the MitraClip system. Safety and midterm durability in the initial EVEREST (Endovascular Internal medicine and Cardiology at the . . Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol 2009;54:686–694. Hadassah university hospital in Jerusalem be- . 4. Krishna M, Zacharowski K. Principles of intra-aortic balloon pump counterpulsa- tween the years 2009 and 2018. He is cur- . tion. Cont Edu Anaesth Crit Care Pain 2009;9:24–28. 5. Buckert D, Markovic S, Kunze M, Wo ¨ hrle J, Rottbauer W, Walcher D. rently working as an academic and . TM . Percutaneous mitral valve repair with the MitraClip NT system in a patient pre- interventional cardiology fellow at the Heart . senting with prolonged cardiogenic shock. Clin Case Rep 2017;5:1807–1810. Institute Hadassah Medical Center. . 6. Melisurgo G, Ajello S, Pappalardo F, Guidotti A, Agricola E, Kawaguchi M, Latib A, Covello RD, Denti P, Zangrillo A, Alfieri O, Maisano F. Afterload mismatch after Mitraclip insertion for functional mitral regurgitation. Am J Cardiol 2014;113: 1844–1850. Supplementary material . . 7. Biner S, Perk G, Kar S, Rafique AM, Slater J, Shiota T, Hussaini A, Chou S, Kronzon I, Siegel RJ. Utility of combined two-dimensional and three-dimensional Supplementary material is available at European Heart Journal - Case . transesophageal imaging for catheter-based mitral valve clip repair of mitral regur- Reports online. . gitation. J Am Soc Echocardiogr 2011;24:611–617.

Journal

European Heart Journal - Case ReportsOxford University Press

Published: Jun 1, 2019

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