Successful transcatheter edge-to-edge repair for atrial functional mitral regurgitation after surgical annuloplasty ring dehiscence: a case report

Abstract

Background: Annuloplasty ring dehiscence (ARD) after surgical mitral valve repair is a rare complication, which causes recurrent mitral regurgitation (MR) and is associated with adverse outcomes in patients with a prohibitive risk of repeat surgery. However, a patient developed severe MR, when challenging transcatheter edge-to-edge repair (TEER) after surgical ring dehiscence, it should be considering the relative efficacy and safety.

Case summary: An 89-year-old man underwent mitral valve repair with an annuloplasty ring for moderate atrial functional MR (AFMR). Post-operative transthoracic echocardiography on Day 7 suggested a dislodged mitral annuloplasty ring and recurrent moderate AFMR. However, the MR developed severely, which led to two hospitalizations for congestive heart failure in the past year. Transoesophageal echocardiography (TOE) was performed carefully to ensure that the TEER clip did not interfere with the dislodged annuloplasty ring. Consequently, only the therapeutic target on the medial side of the A2-P2 region was approached posteriorly behind the peri-ring space, without gripper interference.

Discussion: Transcatheter edge-to-edge repair using the G4-MitraClip® system is feasible and safe in patients with recurrent severe AFMR after surgical mitral valve repair concomitant with ARD. Meticulous simulation with pre-operative TOE is one of the crucial steps for successful outcomes.

Keywords: Annuloplasty ring dehiscence; Atrial functional mitral regurgitation; Case report; Edge-to-edge mitral repair; Transoesophageal echocardiography.

Figure 1

Parasternal long axis view in end-diastole (A) and end-systole (B) and apical long axis view in end-diastole (C) and end-systole (D) with the detached annuloplasty ring (arrow) on transthoracic echocardiography.

Figure 2

Multiplane view presenting the commissural view (left: 20°) and left ventricular out tract view (right: 110°) in transoesophageal echocardiography (TOE) (A: end-diastole, B: end-systole, and arrows: detached annuloplasty ring). Detached annuloplasty ring and atrial functional mitral regurgitation (C and D) and its three-dimensional TOE image (E and F).

Figure 3

Positional relationship of the clip presumed to be the detached annuloplasty ring and the anticipated direction of clip insertion (dashed arrow); on the A2–P2 medial side, there is a possible 5 mm space between the dislodged ring and the shaft.

Figure 4

Clip inserted into the left ventricle in the intraoperative transoesophageal echocardiography (TOE) and success of the anterior gripper (arrow) down without interfering with the ring (A). Fusion of the real TOE image and schematic (B).

Figure 5

Intraoperative transoesophageal echocardiography (TOE) images before (left) and after transcatheter edge-to-edge repair (right) with improved mitral regurgitation.