Ischemic mitral regurgitation and mitral clip insertion

Description

73 year old patient.

• Ischemic heart disease and severely impaired left ventricular systolic function.
• Admitted with shortness of breath and signs of heart failure.
• Mitral regurgitation (MR) was noted on the portable echocardiogram.
• Therefore, the patient underwent a transthoracic and transoesophageal echocardiogram for MR assessment.

Clinical case information

Parasternal long axis view : The left ventricle is dilated in size and the septal wall is thinned and akinetic. Left ventricular systolic function is severely impaired. The left atrium is dilated. The aortic valve is structurally normal. There is tethering of mitral leaflets due to the dilatation of the left ventricle

Parasternal short axis at the level of the mitral valve: Left ventricular systolic function is severely impaired. As it demonstrated with colour Doppler, there is at least moderate mitral regurgitation.

Apical four chamber view : The left ventricle is dilated and function is severely impaired, The left atrium is dilated when indexed to body surface area (volume 82 mls/m2), The right ventricle is normal in size with good systolic function. Right atrium is normal in size.

Apical 4 chamber view with colour Doppler : The left ventricle is dilated and severely impaired. The right ventricle is normal in size with good systolic function. With colour Doppler there is moderate ischemic mitral regurgitation .

Colour Doppler from apical four chamber view : Calculation of the effective regurgitant orifice area via the proximal isovelocity surface area (PISA) principle.

Continuous wave of the mitral regurgitation. Assessment of the effective regurgitant orifice area via the proximal isovelocity surface area (PISA) principle: EROA is estimated as 22 mm2 which is classified as severe for ischemic mitral regurgitation

Transesophageal echocardiogram : Mid esophageal long axis at 129 degrees: it is one of the views for mitral valve assessment in which we are able to assess A2/P2 scallops of the mitral valve. Colour Doppler demonstrates a severe eccentric jet of mitral regurgitation.

Transesophageal echocardiogram : Mid oesophageal bicommisural view at 65 degrees. This is the best view for the measurement of the mitral annulus. With colour Doppler, there is evidence of sevree ischemic mitral regurgitation.

Real time 3D transoesophageal echocardiography : Surgical view from the left atrium towards the left ventricle – there is reduced apposition between the mitral leaflets along all the closure line .

Real time 3D transoesophageal echocardiography with colour Doppler only: Demonstration of severe ischemic mitral regurgitation.

After severe mitral regurgitation diagnosis, the case was discussed to the multidisciplinary meeting and It was decided that mitral clip insertion would be a good therapeutic option.

In the mitral clip procedure a catheter is guided through the femoral vein to reach the heart. The clip is delivered through the catheter to the region of the mitral valve. Upon reaching the mitral valve, it clips the mitral valve leaflets to allow it to close better. The clip is left on the mitral valve while the rest of the delivery system and the catheter are removed.

Mitral clip insertion : Transoesophageal echocardiography: mid oesophageal bicommisural view at 68 degrees. The mitral clip is seen as an echogenous structure in the middle of the mitral valve.

Real time 3D transoesophageal echocardiography : Surgical view from the left atrium towards the left ventricle: The mitral clip is seen as an echogenous structure in the middle of the mitral valve.

Conclusion

After clip procedure mitral regurgitation diminished and heart failure signs resolved so that patient could be discharged home.