<div>Title: Chordal preservation mitral valve replacement for delayed
MitraClip failure</div><div>Authors: Kevin L. Greason MD<sup>1</sup>, Peter C. Spittell
MD<sup>2</sup>, and R. Scott Wright MD<sup>2</sup></div><div>Institutions and Affiliations: Mayo Clinic, Rochester, Minnesota, USA,
(1) Department of Cardiovascular Surgery (2) Department of
Cardiovascular Disease</div><div>Running title: Valve replacement after MitraClip</div><div>Address for correspondence: Kevin L. Greason MD, Department of
Cardiovascular Surgery, Joseph 5-200, 200 First Street, Southwest,
Rochester, Minnesota, USA, 55905; Tel (507) 255-7067; Fax (507)
255-7378; Email
greason.kevin@mayo.edu</div><div>Funding source: none</div><div>Meeting presentation: none.</div><div>Conflict of interest: none.</div><div>Clinical trial registration: none.</div><div>Word Count: 1100</div><div>Abstract:</div><div>Mitral valve replacement may be indicated for delayed MitraClip failure.
Although it would be best to preserve the chordal apparatus during
mitral valve replacement, this has not been reported for delayed
MitraClip failure. The reason is probably because there is almost always
impressive inflammation around the MitraClip which has likely precluded
previous attempts at chordal preservation. We report successful chordal
preservation mitral valve replacement for delayed MitraClip failure.</div><div>Abstract word count: 68</div><div>Introduction:</div><div>MitraClip failure can require mitral valve replacement. Although chordal
preservation is the preferred option for valve replacement, it has not
been described for MitraClip failure. The present case report addresses
this line of reasoning.</div><div>Case report/description:</div><div>The Mayo Clinic Rochester Institutional Review Board waves IRB approval
for a case report. The patient signed a waiver of informed consent at
the time of treatment.</div><div>We were asked to evaluate a 60 y/o man with class III dyspnea and mixed
mitral valve disease related to MitraClip failure. The patient had
chronic atrial fibrillation, cirrhosis (MELD score 9), and history of
ascites with gastrointestinal bleeding.</div><div>At an outside Institution approximately 17 months prior to our
evaluation, he received placement of a single MitraClip (Abbott,
Chicago, Illinois, USA) for severe valve regurgitation. Two months later
he received placement of 2 additional MitraClips to treat persistent
severe mitral valve regurgitation. Neither procedure resolved the valve
regurgitation. He was subsequently denied mitral valve operation at the
outside facility because of the cirrhosis.</div><div>Transthoracic echocardiography at our Institution demonstrated an
ejection fraction of 57% with no regional wall motion abnormality.
Pulmonary hypertension was present with an estimated right ventricular
systolic blood pressure of 76 mm Hg (systemic systolic blood pressure
125 mm Hg). There was also significant mixed mitral valve disease with a
mean diastolic mitral transvalvular gradient of 10 mm Hg (heart rate 74
beats/min) and severe mitral valve regurgitation (multiple eccentric
jets).</div><div>There were no transcatheter treatment options available. We elected to
move ahead with mitral valve operation. Intraoperative transesophageal
echocardiography provided a good image of the problem (Video clip 1).
The mitral valve was exposed through a superior transseptal approach.
Examination demonstrated myxomatous changes of the mitral valve
leaflets. There was also significant inflammation around the previously
placed MitraClips. The valve was not repairable.</div><div>The anterior leaflet of the mitral valve was incised radially
approximately 5 mm from the annulus and the incision continued down
through both commissures. The entire MitraClip/mitral valve leaflet
complex (i.e., free anterior leaflet, MitraClips, and posterior leaflet)
was dropped posterior. Valve replacement sutures went through the free
anterior mitral valve leaflet edge and then the posterior leaflet in a
chordal preservation technique. The suture pledgets were positioned on
the ventricular side. A 33 mm porcine prosthesis was easily sutured into
position. The left atrial appendage was amputated.</div><div>The patient separated from cardiopulmonary bypass without difficulty.
Completion transesophageal echocardiography demonstrated an ejection
fraction of 45% with ventricular pacing induced apical hypokinesis.
There was normal function of the mitral valve prosthesis with trivial
prosthetic and no paravalvular prosthetic regurgitation. The mean
diastolic mitral transvalvular gradient was 4 mm Hg (heart rate 100
beats/min).</div><div>The patient was discharged to home 11 days after operation. Discharge
transthoracic echocardiography demonstrated an ejection fraction of 44%
with no regional wall motion abnormality. There was normal function of
the mitral valve prosthesis: trivial central prosthetic regurgitation,
no paravalvular regurgitation, and a mean diastolic mitral transvalvular
gradient of 6 mm Hg (heart rate 84 beats/min and hemoglobin 8.8 gm/dL).
The MitraClip/mitral valve leaflet complex appeared to be effectively
constrained in the area behind the prosthesis posterior valve strut
(Video clip 2).</div><div>Through 7 months of follow-up, the patient has experienced no
cirrhosis-related complications. He maintains New York Heart Association
class I function. Transthoracic echocardiography demonstrates an
ejection fraction of 40% with no regional wall motion abnormality.
There is continued normal function of the mitral valve prosthesis.</div><div>Comment</div><div>Mitral valve replacement may be indicated for delayed MitraClip failure
(1-4). Surgical dogma dictates chordal preservation is ideal during
valve replacement (5). We did a PUBMED (PubMed.gov, July 16, 2020)
review of the literature and identified no report of chordal
preservation mitral valve replacement for delayed MitraClip failure.</div><div>The present case demonstrates feasibility of chordal preservation mitral
valve replacement for delayed MitraClip failure. Our patient had the
expected MitraClip related phlegmon, but the myxomatous changes of the
mitral valve leaflets likely facilitated procedure success. The
perceived benefits of chordal preservation mitral valve replacement
should not be denied to patients with delayed MitraClip failure.</div><div>Author contributions:</div><div>Kevin L. Greason: Concept/design, drafting article, critical revision of
article, approval of article, data collection.</div><div>Peter C. Spittell: Concept/design, drafting article, critical revision
of article, approval of article, data collection.</div><div>R. Scott Wright: Concept/design, drafting article, critical revision of
article, approval of article, data collection.</div><div>References:</div><ol><li>Takayuki G, Soren S, Kristin R, Harnath A, Grimming O, Soren J, et al.
Surgical revision of failed percutaneous edge-to-edge mitral valve
repair: lessons learned. Interact CardioVasc Thorac Surg 2019; 28:
900-7.</li><li>Kreidel F, Alessandrini H, Wohlmuth P, Schmoeckel M, and Geidel S. Is
surgical or catheter-based interventions an option after an
unsuccessful Mitral Clip? Semin Thorac Surg 2018; 30: 152-7.</li><li>Geidel S, Wohlmuth P, and Schmoeckel M. Survival prediction in
patients undergoing open-heart mitral valve operation after previous
failed MitraClip procedures. Ann Thorac Surg 2016; 101: 952-9.</li><li>Alozie A, Westphal B, Kische S, Kaminski A, Paranskaya L, Bozdag-Turan
I, et al. Surgical revision after percutaneous mitral valve repair by
edge-to-edge device: when the strategy fails in the highest risk
surgical population. Eur J Cardiothorac Surg 2014; 46: 55-60.</li><li>David TE, Uden DE, and Strauss HD. The importance of the mitral
apparatus in left ventricular function after correction of mitral
regurgitation. Circulation 1983; Suppl II: 76-83.</li></ol><div>Video clip 1 legend: Preoperative transesophageal echocardiography 3-D
video image left atrial view of mitral valve demonstrating the 3
MitraClips.</div><div>Video clip 2 legend: Postoperative transthoracic echocardiography image
of apical 4 chamber view of mitral valve demonstrating the
MitraClip/mitral valve leaflet complex being constrained behind the
prosthesis posterior valve strut.</div>