J INVASIVE CARDIOL 2017;29(2):E21-E22.
Key words: mitral regurgitation, infective endocarditis
A 75-year-old man with a history of coronary bypass surgery presented with 3 weeks of fever. A transesophageal echocardiogram (TEE) revealed a 7 mm vegetation on the mitral valve with mild-moderate functional mitral regurgitation (MR) (Figure 1; Videos 1 and 2). After 4 weeks of antibiotics, he presented with New York Heart Association class III dyspnea and repeat TEE demonstrated severe MR (Figure 2; Videos 3 and 4) with the anterior leaflet thickened and retracted with resultant malcoaptation (Videos 5 and 6). Magnetic resonance imaging of the brain showed 2 acute lacunar infarcts. On hospital day 3, he developed profound dyspnea with hypotension and acute renal failure. The patient remained dyspneic and anuric despite maximal medical support. Dialysis was initiated. Surgery was considered prohibitive due to multiple comorbidities. After consultation with Infectious Diseases, it was determined the infection risk was low and transcatheter mitral valve repair (TMVR) was offered.
TMVR was successful, with deployment of two MitraClips (Abbott Vascular) (Videos 7 and 8). The initial left atrial pressure tracings demonstrated V-waves to 57 mm Hg (Figure 3A), which were reduced to 35 mm Hg (Figure 3B). Postprocedure TEE demonstrated mild residual MR (Video 9). He experienced a dramatic response, with the cardiac index rising acutely from 2.0 L/min/m2 to 3.16 L/min/m2. At discharge, the creatinine was 1.0 mg/dL, and he was functional class II. The patient remains on suppressive antibiotics. At 6-month follow-up, he has not developed any signs of infection or worsening heart failure (Figure 4; Videos 10 and 11).
Early surgery is indicated in patients with endocarditis who present with heart failure due to its high mortality.1 However, with prohibitive surgical risk, percutaneous repair remains unchartered territory, as active endocarditis is a contraindication to TMVR.2 The lack of alternatives and the patient’s refractory shock led us to consider TMVR. Several patho-anatomic features suggested TMVR would be effective, including the lack of persistent mobile vegetation, A2-P2 location of regurgitation, and adequate leaflet grasping length. The merits of the procedure outweighed delaying therapy, where the only alternative strategy was palliative care.
This case, the first to our knowledge, demonstrates a potential role of TMVR in treating acute severe MR due to endocarditis. Such a strategy requires a multidisciplinary approach and may be cautiously considered when: (1) surgical risk is prohibitive; (2) patho-anatomic characteristics are favorable; and (3) infection is deemed to be controlled. The long-term risk for recurrent endocarditis and durability of the MitraClip device when used on a post-infective endocarditis degenerative valve remains unknown.
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1. Stout KK, Verrier ED. Acute valvular regurgitation. Circulation. 2009;119:3232-3241.
2. Rogers JH, Franzen O. Percutaneous edge-to-edge MitraClip therapy in the management of mitral regurgitation. Eur Heart J. 2011;32:2350-2357.
From the 1Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota; and the 2Department of Radiology, Mayo Clinic, Rochester, Minnesota.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflict of interest regarding the content herein.
Manuscript submitted August 4, 2016, provisional acceptance given August 5, 2016, final acceptance given August 11, 2016.
Address for correspondence: Pranav Chandrashekar, MBBS, Mayo Clinic, 200 First St. SW, Rochester, MN 55905. Email: email@example.com