The Amplatzer Duct Occluder II offers a feasible method for further reducing mitral regurgitation after a MitraClip procedure, a small case series suggests.
This plug was successfully deployed in all nine patients in the series, all of whom exhibited decreases in mitral regurgitation flow and left atrial pressure. One patient, however, experienced device embolization to the ostial right coronary artery and had to have the device retrieved during the procedure.
Patients who kept their occluders were discharged 1.8 days later with no significant mitral regurgitation remaining on transthoracic echocardiography (all grade 2 or better), Saibal Kar, MD, of Cedars-Sinai Medical Center in Los Angeles, and colleagues reported in their study appearing online in JACC: Cardiovascular Interventions.
These remaining patients also showed improvement to New York Heart Association class I or II by 1 month.
“Our report reveals the efficacy of transcatheter deployment of the Amplatzer for two different residual leak types after the MitraClip procedure to achieve mitral regurgitation reduction and hemodynamic improvement,” the researchers wrote. “The potential role of this technique should be established for challenging cases such as residual commissural mitral regurgitation and intraclip mitral regurgitation.”
Kar and colleagues suggested that for some cases, multiple MitraClips would only leave residual jets between the clips and leave room for clip entanglement. “The treatment option of percutaneous closure of residual mitral regurgitation after MitraClip placement can avoid the risk for clip entanglement and ruptured chordae,” they concluded.
Jason H. Rogers, MD, of the University of California, Davis Medical Center in Sacramento, however, cited the instance of device embolization as a worrying complication: “It is possible that the device was undersized to the defect or that the leaflet integrity at the occluder location was suboptimal. Perhaps the flanking MitraClips were not stable enough to anchor the occluder. Unfortunately, it is not certain how this complication could have been prevented, except to perform a vigorous ‘tug test’ prior to releasing the device,” he wrote in an accompanying editorial.
“Mechanistically, the use of the MitraClip is more stable than the use of occluder devices, because the MitraClip actively grasps both leaflets, is secure, and enhances native leaflet coaptation,” Rogers added.
Indeed, Kar’s report showed that mitral regurgitation worsened in one patient by 30 days.
The single-center study included nine consecutive patients who underwent Amplatzer therapy for residual mitral regurgitation (grade 3 or worse) after MitraClip implantation.
In seven cases, the Amplatzer was placed right after the MitraClip in one visit; two patients had returned for their Amplatzer.
“One must remember that these results are from a highly experienced center and that results from less experienced operators may be worse,” Rogers emphasized. “Importantly, every attempt was made by the investigators to place MitraClips as the primary strategy for mitral regurgitation reduction.”
“The use of an occluder at this point should be considered a ‘bail-out’ strategy after a conscientious attempt at clip placement is made,” he concluded. “We should all adopt a ‘MitraClip first’ and ‘occluder second only if needed’ approach.”
Kar disclosed relationships with Abbott Vascular and St. Jude Medical.
Rogers reported a relationship with Abbott Structural Heart.
JACC: Cardiovascular Interventions
Kubo S, et al “Transcatheter procedure for residual mitral regurgitation after mitraclip implantation using amplatzer duct occluder II” JACC Cardiovasc Interv 2016; DOI: 10.1016/j.jcin.2016.03.011.
JACC: Cardiovascular Interventions
Rogers JH “MitraClip with occluder: augmenting a proven therapy” JACC Cardiovasc Interv 2016; DOI: 10.1016/j.jcin.2016.05.022.