"Edge to edge" percutaneous endovascular repair in primary severe mitral insufficiency, with Mitralclip G4. First experience at the Alcívar Hospital, 2024.

Abstract

Introduction:  Mitral insufficiency (MR) is the most common acquired valve disease globally, its prevalence being higher with aging, representing 7% of the population over 75 years of age. Structural interventionism, particularly transcatheter edge-to-edge repair (TEER), is a valid and less invasive option for patients with severe MR, using devices such as MitraClip, which is a cobalt chrome, polyester-coated device that is inserted via the femoral vein and navigates to the left atrium through a transseptal puncture guided by transesophageal echocardiography. The objective is to present the clinical case of a patient with severe and symptomatic primary MR, with high surgical risk and anatomical feasibility, who underwent edge-to-edge transcatheter repair of the mitral valve with the Mitraclip™️ G4 device, being the first and unique experience at the Alcívar Hospital.

Clinical case: 75-year-old man with a history of high blood pressure. He was admitted with dyspnea, fatigue, and deterioration of NYHA functional class, accompanied by a holosystolic murmur in the mitral focus of intensity 5/6. Morris's sign is present on the EKG. The chest X-ray revealed signs of pulmonary hypertension and a prominent aortic button. With echocardiography, severe primary MI was diagnosed, with A2/P2 segment anterior leaflet prolapse due to first-order chords tending rupture; eccentric jet with Coanda effect, which was corroborated in the transesophageal echo (TEE), where an IM Volume of 156ml was also determined / IM AORE 1.23 cm/max GP 90 mmHg / average GP 48 mmHg / vena contracta 9mm / Separation of the “ Flail”: 4 mm, Posterior leaflet length 11 mm, AVM 4.2 cm2. EuroSCORE of 9.1, STS mortality score was 13.2, and morbidity and mortality score 14.4.

Result: Through femoral access and transseptal catheterization, a MitraClip is introduced with maneuvers of the positioning system passing the mitral valve guided by the 2D and 3D TEE, and capture of both edges of the valve is performed at the site of greatest regurgitation A2/P2 holding the edges for it. Persistence of moderate insufficiency is observed, so a second MitraClip G4 is placed satisfactorily. Doppler measurements are performed, observing mild residual insufficiency. Its adequate implantation is confirmed by angiography and TEE.

Conclusion: Percutaneous repair using the edge-to-edge technique is an effective alternative with a low risk of complications, which improves the quality of life and prognosis in these patients. The first case of MitraClip implantation for the management of severe MR is reported at the Alcívar Hospital in a patient not a candidate for surgery. Complete success was achieved with improvement from severe 4+ insufficiency to mild insufficiency with no clinical relevance. No complications occurred. Echocardiographic control at 3 and 6 months maintains mild mitral regurgitation.