Case Report
Percutaneous treatment of mitral regurgitation by MitraClipTM: report on the first two procedures in Brazil
Tratamento percutâneo da insuficiência mitral por MitraClip®: relato dos dois primeiros procedimentos no Brasil
Fabio S. Brito Jr.a,
, Alexandre Sicilianob, Claudio H. Fischera, Marcelo L. Vieiraa, Arnaldo Rabischoffskib, Fabio Papaa, Marcelo R. Fernandesb, Bernardino Tranchesi Jr.a, Paulo Dutrab, Marco A. Perina
Corresponding author
fabio.brito@einstein.br
Corresponding author. Hospital Israelita Albert Einstein, Intervenção Cardiovascular, Avenida Albert Einstein, 627/701, Morumbi, CEP: 05652-900, São Paulo, SP, Brazil.
Corresponding author. Hospital Israelita Albert Einstein, Intervenção Cardiovascular, Avenida Albert Einstein, 627/701, Morumbi, CEP: 05652-900, São Paulo, SP, Brazil.
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Publicado por Elsevier Editora Ltda" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Bras Cardiol Invasiva. 2015;23:156-60" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 9803 "formatos" => array:3 [ "EPUB" => 115 "HTML" => 8972 "PDF" => 716 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Relato de Caso</span>" "titulo" => "Tratamento percutâneo da insuficiência mitral por MitraClip<span class="elsevierStyleSup">®</span>: relato dos dois primeiros procedimentos no Brasil" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "156" "paginaFinal" => "160" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Percutaneous treatment of mitral regurgitation by MitraClip<span class="elsevierStyleSup">TM</span>: report on the first two procedures in Brazil" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1862 "Ancho" => 2883 "Tamanyo" => 745617 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Ecocardiograma transesofágico pré (<span class="elsevierStyleBold">A</span>, <span class="elsevierStyleBold">B</span> e <span class="elsevierStyleBold">C</span>) e pós-procedimento (<span class="elsevierStyleBold">D</span>, <span class="elsevierStyleBold">E</span> e <span class="elsevierStyleBold">F</span>). Prolapso de ambas as cúspides associado à rotura de corda e flail do segmento A2 (<span class="elsevierStyleBold">A</span> e <span class="elsevierStyleBold">C</span>, seta), gerando refluxo excêntrico posterior importante (<span class="elsevierStyleBold">B</span>), pelo flail gap de 4<span class="elsevierStyleHsp" style=""></span>mm. Após implante de um clipe (<span class="elsevierStyleBold">D</span>), redução significativa do refluxo (<span class="elsevierStyleBold">E</span>) e formação do duplo orifício mitral (<span class="elsevierStyleBold">F</span>).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Fabio S. Brito, Alexandre Siciliano, Claudio H. Fischer, Marcelo L. Vieira, Arnaldo Rabischoffski, Fabio Papa, Marcelo R. Fernandes, Bernardino Tranchesi, Paulo Dutra, Marco A. Perin" "autores" => array:10 [ 0 => array:3 [ "nombre" => "Fabio S." 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"apellidos" => "Perin" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2214123515000447" "doi" => "10.1016/j.rbciev.2015.12.018" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2214123515000447?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0104184315000508?idApp=UINPBA00004N" "url" => "/01041843/0000002300000002/v2_201612240359/S0104184315000508/v2_201612240359/es/main.assets" ] ] "itemAnterior" => array:20 [ "pii" => "S2214123515000435" "issn" => "22141235" "doi" => "10.1016/j.rbciev.2015.12.017" "estado" => "S300" "fechaPublicacion" => "2015-04-01" "aid" => "36" "copyright" => "Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Bras Cardiol Invasiva. 2015;23:152-5" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2104 "formatos" => array:3 [ "EPUB" => 304 "HTML" => 1280 "PDF" => 520 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Coronary occlusion after TAVI: safety strategy report" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "152" "paginaFinal" => "155" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Oclusão coronariana após TAVI: relato de estratégia de segurança" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 708 "Ancho" => 2167 "Tamanyo" => 232072 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">(<span class="elsevierStyleBold">A</span>) On the left, demonstration of the therapeutic armamentarium: balloon expandable prosthesis release system into descending aorta (1) over Amplatz SuperStiff<span class="elsevierStyleSup">TM</span> guide wire with its end into the left ventricle (2); a temporary pacemaker electrode into the right ventricle (3); pigtail catheter into the right coronary sinus (4); JR 6 F guide catheter (5) above the sinus of Valsalva; two 0.014-inch Extra Support guide wires and coronary stent placed distally into the right coronary artery (6); permanent pacemaker electrodes into the right ventricle and atrium (7 and 8) (<span class="elsevierStyleBold">B</span>). Release of balloon expandable aortic valve prosthesis, with percutaneous coronary intervention system positioned into the right coronary artery. (<span class="elsevierStyleBold">C</span>) Control aortography showing right and left coronary artery patency and minimum aortic regurgitation.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Fabio Rodrigo Furini, Valter Correia de Lima, Fabio Sândoli de Brito, Alessandra Teixeira de Oliveira, Marcela da Cunha Sales, Fernando Antonio Lucchese" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Fabio Rodrigo" "apellidos" => "Furini" ] 1 => array:2 [ "nombre" => "Valter Correia de" "apellidos" => "Lima" ] 2 => array:3 [ "nombre" => "Fabio Sândoli de" "apellidos" => "Brito" "sufijo" => "Jr." ] 3 => array:2 [ "nombre" => "Alessandra Teixeira de" "apellidos" => "Oliveira" ] 4 => array:2 [ "nombre" => "Marcela da Cunha" "apellidos" => "Sales" ] 5 => array:2 [ "nombre" => "Fernando Antonio" "apellidos" => "Lucchese" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0104184315000491" "doi" => "10.1016/j.rbci.2015.12.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0104184315000491?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2214123515000435?idApp=UINPBA00004N" "url" => "/22141235/0000002300000002/v2_201612270115/S2214123515000435/v2_201612270115/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case Report</span>" "titulo" => "Percutaneous treatment of mitral regurgitation by MitraClip<span class="elsevierStyleSup">TM</span>: report on the first two procedures in Brazil" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "156" "paginaFinal" => "160" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Fabio S. Brito, Alexandre Siciliano, Claudio H. Fischer, Marcelo L. Vieira, Arnaldo Rabischoffski, Fabio Papa, Marcelo R. Fernandes, Bernardino Tranchesi, Paulo Dutra, Marco A. Perin" "autores" => array:10 [ 0 => array:5 [ "nombre" => "Fabio S." "apellidos" => "Brito" "sufijo" => "Jr." "email" => array:1 [ 0 => "fabio.brito@einstein.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Alexandre" "apellidos" => "Siciliano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Claudio H." 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"apellidos" => "Fernandes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:4 [ "nombre" => "Bernardino" "apellidos" => "Tranchesi" "sufijo" => "Jr." "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Paulo" "apellidos" => "Dutra" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "Marco A." "apellidos" => "Perin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hospital Israelita Albert Einstein, São Paulo, SP, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Pró-Cardíaco, Rio de Janeiro, RJ, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author. Hospital Israelita Albert Einstein, Intervenção Cardiovascular, Avenida Albert Einstein, 627/701, Morumbi, CEP: 05652-900, São Paulo, SP, Brazil." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Tratamento percutâneo da insuficiência mitral por MitraClip<span class="elsevierStyleSup">®</span>: relato dos dois primeiros procedimentos no Brasil" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1368 "Ancho" => 2168 "Tamanyo" => 370799 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography pre- (<span class="elsevierStyleBold">A</span>, <span class="elsevierStyleBold">B</span>, and <span class="elsevierStyleBold">C</span>) and post-procedure (<span class="elsevierStyleBold">D</span>, <span class="elsevierStyleBold">E</span>, and <span class="elsevierStyleBold">F</span>). Note the coaptation gap between the cusps (<span class="elsevierStyleBold">A</span>, arrow) due to prolapse of segments P2 and P3, and <span class="elsevierStyleItalic">chordae tendineae</span> rupture in P2 (<span class="elsevierStyleBold">C</span>, arrow) causing eccentric anterolateral regurgitation (<span class="elsevierStyleBold">B</span>). After MitraClip<span class="elsevierStyleSup">TM</span> implantation in the medial border of P2 (<span class="elsevierStyleBold">D</span> and <span class="elsevierStyleBold">F</span>), there was significant reduction of regurgitation (<span class="elsevierStyleBold">E</span>) and formation of double mitral orifice, with the characteristic “8” image in the three-dimensional echocardiography (<span class="elsevierStyleBold">F</span>).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Mitral valve regurgitation is one of the most common acquired valvular diseases, with a prevalence of approximately 7 to 10% in the population aged > 75 years.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The treatment of mitral regurgitation is traditionally based on clinical management with medications, resynchronization, and especially valve repair or valve replacement surgery.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, despite guideline recommendations, approximately 50% of the patients are not treated surgically, due to the presence of high surgical risk caused by advanced age, left ventricular dysfunction, or comorbidities.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> For this reason, more recently the focus of research in this area has changed to the development of new and less invasive percutaneous devices for the treatment of mitral valve regurgitation. Among them, the MitraClip<span class="elsevierStyleSup">TM</span> system (Abbott Vascular, Redwood City, USA) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) is one of the most promising. This device was approved for clinical use in Europe in March 2008, and in the United States in October 2013. To date, more than 25,000 patients have already benefited from this new treatment modality, predominantly used in individuals at high surgical risk. In Brazil, the MitraClip<span class="elsevierStyleSup">TM</span> was approved for use in the end of 2014. This report describes the first two procedures performed in Brazil for percutaneous treatment of mitral valve regurgitation using the MitraClip<span class="elsevierStyleSup">TM</span> device.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case reports</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">Female patient, 97 years old, admitted to Hospital Israelita Albert Einstein, in São Paulo (SP), due to sudden onset of congestive heart failure, functional class IV. Evaluations by transthoracic echocardiography (TTE) and subsequently by two-dimensional transesophageal echocardiography (TEE) showed severe mitral valve regurgitation (4+/4+), due to mitral valve posterior leaflet prolapse (segments P2 and P3) associated with <span class="elsevierStyleItalic">chordae tendineae</span> rupture (P2 segment), resulting in extensive coaptation gap (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a>A to 2C). The left atrium measured 48<span class="elsevierStyleHsp" style=""></span>mm, and systolic blood pressure in the pulmonary artery was estimated at 53<span class="elsevierStyleHsp" style=""></span>mmHg. Left ventricular function estimated by ejection fraction was normal. Despite the prolonged hospital stay (45 days) for drug treatment optimization, the patient had repeated episodes of acute pulmonary edema, requiring intermittent intensive care and characterizing treatment resistance. Due to the advanced age and comorbidities such as renal failure, the medical team considered the surgical risk to be unacceptable. Estimates of surgical mortality by logistic EuroSCORE and Society of Thoracic Surgeons (STS) risk score were 21.1 and 18.4%, respectively. For this reason, the percutaneous transseptal mitral valvuloplasty with MitraClip<span class="elsevierStyleSup">TM</span> device was indicated.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The procedure was performed in a hybrid operating room on January 6, 2015, with the patient under general anesthesia, and guided by three-dimensional TEE. Heparin was administered at a dose of 10,000 IU, aiming to achieve an activated clotting time of 300 to 350<span class="elsevierStyleHsp" style=""></span>seconds. Right femoral venipuncture was performed, followed by transseptal puncture to obtain access to the left atrium. A 24 F MitraClip<span class="elsevierStyleSup">TM</span> system catheter was introduced in the left atrium, being directed to the mitral valve aided by fluoroscopy and three-dimensional TEE. Several two- and three-dimensional TEE images were used to achieve adequate positioning of the clip, perpendicular to the mitral commissure and over the regurgitation jet. The clip was then advanced into the left ventricle, with open arms. Small additional adjustments in the clip position were guided by two- and three-dimensional TEE.</p><p id="par0020" class="elsevierStylePara elsevierViewall">When optimal positioning was obtained, the clip was closed, capturing equivalent portions of the mitral valve cusps (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>D). An immediate reduction was observed in mitral regurgitation intensity, from 4+/4+ to 2+/4+, observing the characteristic image of double mitral orifice (<a class="elsevierStyleCrossRef" href="#fig0010">Figs. 2</a>E and 2F). The mean transvalvular pressure gradient was 4<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The clip was released from the delivery system. The catheter was removed, and hemostasis was achieved with a single Perclose ProGlide<span class="elsevierStyleSup">TM</span> (Abbott Vascular, Redwood City, USA) device applied to the puncture site in the femoral vein. The procedure time (clip time) was 95<span class="elsevierStyleHsp" style=""></span>minutes. A total of 50<span class="elsevierStyleHsp" style=""></span>mL of iodinated contrast was used to perform the baseline left ventriculography, and after the procedure, the patient was extubated and taken to the intensive care unit. Worsening of renal function ensued, requiring hemodialysis. There was significant improvement in heart failure symptoms and the TTE performed 1 and 4 days after the procedure disclosed only mild mitral regurgitation (1+/4+). On the fourth day after the intervention, when the patient was progressing with significant heart failure symptom improvement, she suddenly developed cardiogenic shock and respiratory failure due to massive pulmonary embolism, and subsequently died.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Case 2</span><p id="par0030" class="elsevierStylePara elsevierViewall">Female patient, 93 years old, with hypertension, diabetes, obesity, and hypothyroidism, admitted to the emergency department of Hospital Pro-Cardíaco, in Rio de Janeiro (RJ), with functional class IV progressive congestive heart failure, which had started 45 days before. On admission, atrial fibrillation of unknown duration was observed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Since 2006, the patient had a diagnosis of mild mitral valve regurgitation due to prolapse. Evaluations by TTE and subsequently by TEE performed during hospitalization disclosed the presence of severe mitral valve regurgitation (4+/4+) with Coanda effect, due to prolapse of both cusps, associated with <span class="elsevierStyleItalic">chordae tendineae</span> rupture and A2 flail (<a class="elsevierStyleCrossRef" href="#fig0015">Figs. 3</a>A to 3C). The left atrium measured 50<span class="elsevierStyleHsp" style=""></span>mm, and mean systolic blood pressure in the pulmonary artery was estimated at 50<span class="elsevierStyleHsp" style=""></span>mmHg. Left ventricular function estimated by ejection fraction was normal.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">She was submitted to several unsuccessful attempts at clinical compensation, despite the use of furosemide in continuous infusion, in addition to inotropic (milrinone) and vasodilators. The patient developed anasarca, severe hyponatremia, and hypokalemic metabolic alkalosis, with continuous ultrafiltration and non-invasive ventilation being indicated. Due to her advanced age and comorbidities such as renal failure, she was considered as a high surgical risk patient by the medical team, with mortality estimated by logistic EuroSCORE and STS risk score of 49.3 and 48%, respectively. For this reason, percutaneous transseptal mitral valvuloplasty with the MitraClip<span class="elsevierStyleSup">TM</span> device was indicated.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The procedure was performed in a hybrid operating room on January 16, 2015, with the patient under general anesthesia, and guided by TEE. The same technique described for the previous case was employed, using a single clip. An immediate reduction in mitral regurgitation intensity was obtained, from 4+/4+ to 2+/4+, creating the double mitral orifice (<a class="elsevierStyleCrossRef" href="#fig0015">Figs. 3</a>D to 3F).</p><p id="par0050" class="elsevierStylePara elsevierViewall">The mean transvalvular pressure gradient was 4<span class="elsevierStyleHsp" style=""></span>mmHg. After catheter removal, hemostasis was obtained by manual compression. The procedure time (clip time) was 70<span class="elsevierStyleHsp" style=""></span>minutes. Iodinated contrast was not used in this procedure. The patient was extubated and taken to the intensive care unit. She had a slow, but progressive recovery of spontaneous diuresis and stabilization of nitrogenous waste. Weaning of vasoactive amines was carried out, as well as of dialytic ultrafiltration.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The TEE performed 12 days after the procedure disclosed the presence of mild mitral regurgitation (1+/4+). She was discharged 15 days after the mitral clip implantation, walking with assistance and receiving oral medications: amiodarone, bisoprolol, furosemide, spironolactone, rivaroxaban, and pregabalin. At the 6 month follow-up, the patient was in functional class II.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">The MitraClip<span class="elsevierStyleSup">TM</span> system was recently approved for clinical use in Brazil for the percutaneous treatment of functional or degenerative mitral valve regurgitation. This device is based on the Alfieri procedure, which creates a double orifice by placing a suture between the A2 and P2 segments of the mitral valve cusps.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The randomized clinical trial EVEREST II (Endovascular Valve Edge-to-Edge Repair Study) demonstrated the safety and the efficacy of MitraClip<span class="elsevierStyleSup">TM</span> in selected cases, with results maintained up to the 4 year follow-up.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> In that study, the percutaneous repair was less effective to reduce the mitral regurgitation intensity than conventional surgical treatment. However, it was at least as safe as the surgical approach, with equivalent rates of death, infarction, and stroke, in addition to less need for blood transfusions. Additionally, the percutaneous treatment determined an equivalent improvement in heart failure symptoms and quality of life.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Therefore, it has become an excellent alternative for the treatment of mitral valve regurgitation in high surgical risk patients, as in the two cases reported here, representing a pioneering experience in Brazil. These two patients had degenerative mitral regurgitation, due to prolapse/flail, associated with <span class="elsevierStyleItalic">chordae tendineae</span> rupture. In both cases, a significant reduction in mitral regurgitation intensity was obtained with the use of a single clip. The control echocardiograms performed within the first days after the procedure confirmed treatment efficacy, with mild residual mitral regurgitation in the two patients. The first patient died on the fourth day after the procedure due to massive pulmonary embolism, probably due to prolonged immobility in the hospital bed, despite the anticoagulation scheme started 2 days after the intervention. There is no report in the literature of this complication associated with the mitral clip use. The second patient showed significant clinical improvement and was in functional class II at the 8 month clinical follow-up.</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is noteworthy that knowledge of mitral valve anatomy and the interaction between the interventional cardiologist and the echocardiographist are crucial to procedural success, as this intervention is guided, almost entirely, by the images generated by the two- and three-dimensional TEE. There is no need to use iodinated contrast with the MitraClip<span class="elsevierStyleSup">TM</span> system. Hemorrhagic (cardiac tamponade) and embolic (stroke) complications, although rare, can occur due to transseptal puncture and left atrial manipulation with thick-caliber catheters.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Constant checking of anticoagulation levels (target activated clotting time between 300 and 350<span class="elsevierStyleHsp" style=""></span>seconds) during the procedure is essential to prevent embolic complications.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Although in both cases reported here the MitraClip<span class="elsevierStyleSup">TM</span> was used for the treatment of degenerative mitral regurgitation, its use for the treatment of functional mitral regurgitation is currently more frequent.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> Therefore, the MitraClip<span class="elsevierStyleSup">TM</span> should be considered as an alternative to conventional surgical treatment in selected patients with degenerative or functional mitral regurgitation, especially when the surgical risk is high due to advanced age and the presence of comorbidities or significant left ventricular dysfunction.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Some anatomical conditions, previously considered contraindications to the procedure in the EVEREST study, have recently become more acceptable for the MitraClip<span class="elsevierStyleSup">TM</span> approach with the increasing experience of surgeons. However, some restrictions remain, among which are: significant calcification in the target location for clipping (cusp edge); degenerative lesions caused by rheumatic disease and endocarditis, due to severe deformity and cusp lesion; posterior cusp length ≤ 7<span class="elsevierStyleHsp" style=""></span>mm; coaptation gap > 5<span class="elsevierStyleHsp" style=""></span>mm between the cusp borders; gap ≥ 10<span class="elsevierStyleHsp" style=""></span>mm between the borders of the anterior and posterior cusps caused by flail (flail gap).</p><p id="par0075" class="elsevierStylePara elsevierViewall">In conclusion, the two cases reported in this article have shown the great potential of this innovative technology for percutaneous treatment of mitral valve regurgitation, which should be increasingly used in Brazil. The near future will bring the introduction of other technologies, including annuloplasty devices and prostheses for transcatheter prosthesis implantation, expanding the horizons of interventional cardiology and benefiting an even greater number of patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding source</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres782826" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec781796" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres782827" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec781795" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case reports" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 1" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Case 2" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding source" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 9 => array:2 [ "identificador" => "xack262061" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-02" "fechaAceptado" => "2015-06-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec781796" "palabras" => array:4 [ 0 => "Mitral valve insufficiency" 1 => "Mitral valve" 2 => "Heart valve prosthesis implantation" 3 => "Catheters" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec781795" "palabras" => array:4 [ 0 => "Insuficiência da valva mitral" 1 => "Valva mitral" 2 => "Implante de prótese de valva cardíaca" 3 => "Cateteres" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The MitraClip<span class="elsevierStyleSup">TM</span> system has been recently approved for clinical use in Brazil for percutaneous treatment of mitral valve regurgitation. This device is based on the Alfieri surgical procedure, creating a double orifice by bringing together the central segments of the two mitral valve cusps. This report describes the first two procedures performed in Brazil using this device. Two female patients considered to be at high surgical risk due to advanced age and presence of comorbidities were treated, with degenerative mitral regurgitation due to prolapse/flail, associated with <span class="elsevierStyleItalic">chordae tendineae</span> rupture. In both cases, significant mitral regurgitation intensity reduction was obtained using the MitraClip<span class="elsevierStyleSup">TM</span>, demonstrating the great potential of this innovative technology for the percutaneous treatment of mitral valve regurgitation.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">O sistema MitraClip<span class="elsevierStyleSup">®</span> foi recentemente aprovado para uso clínico no Brasil para o tratamento percutâneo da insuficiência valvar mitral. Esse dispositivo se baseia na cirurgia de Alfieri, criando um orifício duplo pela união central das duas cúspides da valva mitral. Descrevemos aqui os dois primeiros procedimentos realizados em nosso meio utilizando esse dispositivo. Tratam-se de duas pacientes do sexo feminino, consideradas de alto risco cirúrgico pela idade avançada e pela presença de comorbidades, portadoras de insuficiência mitral degenerativa por prolapso/<span class="elsevierStyleItalic">flail</span> associado à rotura de cordoalhas. Nos dois casos, obteve-se redução expressiva da intensidade da regurgitação mitral com a utilização do MitraClip<span class="elsevierStyleSup">®</span>, demonstrando o grande potencial dessa tecnologia inovadora para o tratamento percutâneo da insuficiência valvar mitral.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:1 [ "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Peer Review under the responsability of Sociedade Brasileira de Hemodinâmica e Cardiologia Intervencionista.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 990 "Ancho" => 2168 "Tamanyo" => 141004 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MitraClip<span class="elsevierStyleSup">TM</span> Device (left) and its delivery system (right). Each arm (<span class="elsevierStyleBold">A</span>) of the clip is 4<span class="elsevierStyleHsp" style=""></span>mm wide and 8<span class="elsevierStyleHsp" style=""></span>mm long. The clips (<span class="elsevierStyleBold">B</span>) are used to hold the cusps of the mitral valve in the clip arms. The steerable catheter is a 24 F and has shunters (<span class="elsevierStyleBold">C</span> and <span class="elsevierStyleBold">E</span>) to guide and correctly position the clip. The stabilizer (<span class="elsevierStyleBold">D</span>) is used to support the MitraClip<span class="elsevierStyleSup">TM</span> delivery system.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1368 "Ancho" => 2168 "Tamanyo" => 370799 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography pre- (<span class="elsevierStyleBold">A</span>, <span class="elsevierStyleBold">B</span>, and <span class="elsevierStyleBold">C</span>) and post-procedure (<span class="elsevierStyleBold">D</span>, <span class="elsevierStyleBold">E</span>, and <span class="elsevierStyleBold">F</span>). Note the coaptation gap between the cusps (<span class="elsevierStyleBold">A</span>, arrow) due to prolapse of segments P2 and P3, and <span class="elsevierStyleItalic">chordae tendineae</span> rupture in P2 (<span class="elsevierStyleBold">C</span>, arrow) causing eccentric anterolateral regurgitation (<span class="elsevierStyleBold">B</span>). After MitraClip<span class="elsevierStyleSup">TM</span> implantation in the medial border of P2 (<span class="elsevierStyleBold">D</span> and <span class="elsevierStyleBold">F</span>), there was significant reduction of regurgitation (<span class="elsevierStyleBold">E</span>) and formation of double mitral orifice, with the characteristic “8” image in the three-dimensional echocardiography (<span class="elsevierStyleBold">F</span>).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1397 "Ancho" => 2168 "Tamanyo" => 516101 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transesophageal echocardiography pre- (<span class="elsevierStyleBold">A</span>, <span class="elsevierStyleBold">B</span>, and <span class="elsevierStyleBold">C)</span> and post-procedure (<span class="elsevierStyleBold">D</span>, <span class="elsevierStyleBold">E</span>, and <span class="elsevierStyleBold">F</span>). Prolapse of both cusps, associated with <span class="elsevierStyleItalic">chordae tendineae</span> rupture and A2 flail (<span class="elsevierStyleBold">A</span> and <span class="elsevierStyleBold">C</span>, arrow), generating significant posterior eccentric regurgitation (<span class="elsevierStyleBold">B</span>), due to 4-mm flail gap. After the implantation of one clip (<span class="elsevierStyleBold">D</span>), significant reduction in regurgitation (<span class="elsevierStyleBold">E</span>) and formation of the double mitral orifice (<span class="elsevierStyleBold">F</span>) were observed.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Iung" 1 => "G. Baron" 2 => "E.G. Butchart" 3 => "F. Delahaye" 4 => "C. Gohlke-Barwolf" 5 => "O.W. 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"fecha" => "2012" "volumen" => "14" "numero" => "9" "paginaInicial" => "1050" "paginaFinal" => "1055" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22685268" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous mitral valve repair for mitral regurgitation in high-risk patients: results of the EVEREST II study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.D. Glower" 1 => "S. Kar" 2 => "A. Trento" 3 => "D.S. Lim" 4 => "T. Bajwa" 5 => "R. Quesada" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2013.12.062" "Revista" => array:7 [ "tituloSerie" => "J Am Coll Cardiol." "fecha" => "2014" "volumen" => "64" "numero" => "2" "paginaInicial" => "172" "paginaFinal" => "181" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25011722" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack262061" "titulo" => "Acknowledgements" "texto" => "<p id="par0090" class="elsevierStylePara elsevierViewall">The authors would like to thank the technical support provided by Mr. Flavio Toledo (Abbott). His extensive knowledge of the MitraClip<span class="elsevierStyleSup">TM</span> system significantly contributed to the success of these procedures.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22141235/0000002300000002/v2_201612270115/S2214123515000447/v2_201612270115/en/main.assets" "Apartado" => array:4 [ "identificador" => "43274" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22141235/0000002300000002/v2_201612270115/S2214123515000447/v2_201612270115/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2214123515000447?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 0 | 1 |
| 2024 October | 18 | 4 | 22 |
| 2024 September | 20 | 4 | 24 |
| 2024 August | 12 | 7 | 19 |
| 2024 July | 15 | 4 | 19 |
| 2024 June | 31 | 2 | 33 |
| 2024 May | 31 | 3 | 34 |
| 2024 April | 50 | 4 | 54 |
| 2024 March | 30 | 11 | 41 |
| 2024 February | 26 | 6 | 32 |
| 2024 January | 39 | 8 | 47 |
| 2023 December | 52 | 14 | 66 |
| 2023 November | 28 | 4 | 32 |
| 2023 October | 34 | 5 | 39 |
| 2023 September | 16 | 2 | 18 |
| 2023 August | 22 | 7 | 29 |
| 2023 July | 30 | 10 | 40 |
| 2023 June | 20 | 3 | 23 |
| 2023 May | 74 | 11 | 85 |
| 2023 April | 51 | 3 | 54 |
| 2023 March | 39 | 4 | 43 |
| 2023 February | 24 | 6 | 30 |
| 2023 January | 30 | 8 | 38 |
| 2022 December | 32 | 5 | 37 |
| 2022 November | 37 | 6 | 43 |
| 2022 October | 37 | 6 | 43 |
| 2022 September | 25 | 6 | 31 |
| 2022 August | 24 | 14 | 38 |
| 2022 July | 22 | 12 | 34 |
| 2022 June | 18 | 6 | 24 |
| 2022 May | 11 | 9 | 20 |
| 2022 April | 30 | 9 | 39 |
| 2022 March | 32 | 29 | 61 |
| 2022 February | 18 | 24 | 42 |
| 2022 January | 10 | 16 | 26 |
| 2021 December | 12 | 21 | 33 |
| 2021 November | 14 | 18 | 32 |
| 2021 October | 20 | 16 | 36 |
| 2021 September | 22 | 8 | 30 |
| 2021 August | 12 | 21 | 33 |
| 2021 July | 11 | 12 | 23 |
| 2021 June | 20 | 5 | 25 |
| 2021 May | 12 | 10 | 22 |
| 2021 April | 54 | 12 | 66 |
| 2021 March | 17 | 9 | 26 |
| 2021 February | 15 | 4 | 19 |
| 2021 January | 7 | 8 | 15 |
| 2020 December | 12 | 3 | 15 |
| 2020 November | 10 | 5 | 15 |
| 2020 October | 7 | 6 | 13 |
| 2020 September | 9 | 9 | 18 |
| 2020 August | 13 | 13 | 26 |
| 2020 July | 6 | 4 | 10 |
| 2020 June | 5 | 4 | 9 |
| 2020 May | 8 | 11 | 19 |
| 2020 April | 5 | 3 | 8 |
| 2020 March | 7 | 6 | 13 |
| 2020 February | 8 | 6 | 14 |
| 2020 January | 7 | 19 | 26 |
| 2019 December | 20 | 7 | 27 |
| 2019 November | 10 | 6 | 16 |
| 2019 October | 11 | 10 | 21 |
| 2019 September | 12 | 5 | 17 |
| 2019 August | 2 | 2 | 4 |
| 2019 July | 8 | 14 | 22 |
| 2019 June | 14 | 11 | 25 |
| 2019 May | 7 | 20 | 27 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 1 | 0 | 1 |
| 2018 September | 13 | 1 | 14 |
| 2018 August | 39 | 14 | 53 |
| 2018 July | 35 | 12 | 47 |
| 2018 June | 54 | 10 | 64 |
| 2018 May | 48 | 9 | 57 |
| 2018 April | 58 | 8 | 66 |
| 2018 March | 94 | 8 | 102 |
| 2018 February | 47 | 11 | 58 |
| 2018 January | 19 | 6 | 25 |
| 2017 December | 39 | 9 | 48 |
| 2017 November | 18 | 8 | 26 |
| 2017 October | 38 | 10 | 48 |
| 2017 September | 35 | 9 | 44 |
| 2017 August | 41 | 14 | 55 |
| 2017 July | 40 | 14 | 54 |
| 2017 June | 49 | 16 | 65 |
| 2017 May | 69 | 10 | 79 |
| 2017 April | 172 | 15 | 187 |
| 2017 March | 28 | 15 | 43 |
| 2017 February | 31 | 12 | 43 |
| 2017 January | 25 | 10 | 35 |
| 2016 December | 28 | 32 | 60 |
| 2016 November | 26 | 7 | 33 |
| 2016 October | 35 | 12 | 47 |
| 2016 September | 52 | 6 | 58 |
| 2016 August | 26 | 7 | 33 |
| 2016 July | 29 | 7 | 36 |
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