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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1465-1469
Transcatheter mitral valve repair with a mitraclip for severe mitral regurgitation in a patient on hemodialysis

1 Department of Internal Medicine, Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Kawasaki, Japan
2 Department of Internal Medicine, Division of Cardiology, St. Marianna University School of Medicine, Kawasaki, Japan

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Date of Web Publication4-May-2022


A 55-year-old male patient undergoing hemodialysis (HD) had shortness of breath, New York Heart Association (NYHA) class IIm (moderate limitation of physical activity) due to chronic heart failure. His past medical history was remarkable for chronic heart diseases and severe functional mitral regurgitation (MR), with an ejection fraction of only 33%. The cardiologist considered this severe MR as the cause of his symptom. Due to the multiple comorbidities and low cardiac function, transcatheter mitral valve repair (TMVR) using a MitraClip was selected as an alternative to surgery. TMVR with MitraClip was successfully performed. Postoperatively, the degree of MR decreased from severe to trivial, with an obvious improvement in symptoms to NYHA class I. He was discharged without any postoperative complications. TMVR with MitraClip is an effective nonsurgical treatment for mitral valve disease in HD patients with multiple comorbidities.

How to cite this article:
Sato H, Sakurada T, Kojima S, Okamoto T, Shibagaki Y, Ishibashi Y, Izumo M, Akashi YJ. Transcatheter mitral valve repair with a mitraclip for severe mitral regurgitation in a patient on hemodialysis. Saudi J Kidney Dis Transpl 2021;32:1465-9

How to cite this URL:
Sato H, Sakurada T, Kojima S, Okamoto T, Shibagaki Y, Ishibashi Y, Izumo M, Akashi YJ. Transcatheter mitral valve repair with a mitraclip for severe mitral regurgitation in a patient on hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 25];32:1465-9. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1465/344769

   Introduction Top

Transcatheter mitral valve repair (TMVR) with the MitraClip is an emerging alternative therapy for patients who cannot undergo traditional valve replacement surgery. Although this treatment is not contraindicated even in hemodialysis (HD) patients who are at high risk of surgery, there are few reports of this procedure in HD patients so far. Herein we describe a successful case of MitraClip in a HD patient who had multiple comorbidities.

   Case Report Top

A 55-year-old male consulted a cardiologist due to shortness of breath, New York Heart Association (NYHA) class IIm due to chronic heart failure. His past medical history was remarkable for heart diseases, including dilated cardiomyopathy secondary to ischemic heart disease that was under treatment for 14 years, coronary artery stenosis that was treated twice with percutaneous coronary intervention two and three years before this consultation, atrial fibrillation treated with radiofrequency catheter ablation, and three admissions for acute heart failure. In addition, he had type 2 diabetes mellitus that was under treatment for 20 years, and had been on HD due to diabetic nephropathy for four years. He was a non-smoker and non-drinker. His family history was not remarkable.

His laboratory data were unremarkable for an HD patient. Chest X-ray indicated cardiomegaly (cardiothoracic ratio: 63%). Transthoracic echocardiography showed severe functional mitral regurgitation (MR), with an ejection fraction of only 33%. The attending cardiologist considered the severe MR to be the cause of his progressive heart failure. Due to the presence of multiple complications and his low cardiac function, surgical treatment was contraindicated and TMVR using a MitraClip was selected instead.

TMVR with MitraClip was successfully performed using two clips between the A2 and P2 areas of the mitral valve (MV) under general anesthesia, at the maximum point of MR flow reduction. Intraoperative transesophageal echocardiography showed significant reduction of MR flow after the procedure [Figure 1]. Thereafter, the degree of MR decreased from severe to trivial, with a decrease in the regurgitant jet area from 19% to 6%, and an obvious improvement in his symptoms to NYHA class I. He was discharged on day 6 without any postoperative complications.
Figure 1: Two-dimensional transesophageal (a and b) and transthoracic echocardiography (c and d). (a and c) significant mitral regurgitation before the procedure. (b and d) only trivial mitral regurgitation was found after MitraClip implantation.

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The authors obtained all appropriate consent forms from the patient for the publication of this case report.

   Discussion Top

TMVR with the MitraClip is an emerging alternative therapy for patients who cannot tolerate MV replacement surgery. HD increases the surgical risk of patients with MV disease, making them potential candidates for this treatment. In this case, TMVR with MitraClip successfully improved the patient’s heart failure symptoms and decreased the severity of MR despite the multiple comorbidities.

Although the initial treatment of MR is conservative, MV replacement surgery or TMVR is required in refractory cases. Regarding surgical treatment, a European study in 2012 reported that almost half the patients with >NYHA class II heart failure due to severe MR did not undergo surgical treatment.[1] Further, more severe MR with a low ejection fraction is associated with a worse prognosis. Surgical mitral repair in HD patients requires careful management of blood pressure, electrolyte disturbances, metabolic acidosis, anemia, myocardial protection, bleeding, malnutrition, and glucose intolerance;[2] hence, a higher rate of perioperative mortality and poor long-term survival rates in patients on HD who undergo open-heart surgery have been previously reported.[3] That study summarized the results of 863 patients undergoing cardiac surgery under cardiopulmonary bypass over a 30-year period, and reported that the perioperative mortality rate for isolated cardiac valve operation was 19.3%. Therefore, alternative treatment to surgical mitral repair is required for HD-dependent patients who are at high risk for surgery.

TMVR with MitraClip has been developed as a less invasive treatment option for patients with severe MR who are contraindicated for surgery. The MitraClip procedure is based on the surgical technique reported by Alfieri et al.[4] They sutured two free edges of the MV scallops (anterior: A2 and posterior: P2) in a patient with degenerative MR. Maisano et al also reported this technique’s efficacy and safety.[5] TMVR by MitraClip mimics this “edge to edge” procedure via a transseptal approach by a catheter inserted in the femoral vein. MitraClip of both anterior and posterior leaflets of the MV decreases MV orifice area and reduces the regurgitant mitral flow.

The EVEREST II trial, which evaluated the 5-year clinical outcomes and durability of percutaneous MV repair with the MitraClip compared with conventional MV surgery, reported increased rates of surgery and greater severity of MR in the MitraClip group, although the survival rate, improvement of symptoms, and left ventricular function were almost equal.[6] Comparable low rates of re-surgery for MV dysfunction were also seen in both groups between one and five years, and MitraClip was superior to surgery in terms of perioperative safety. However, patients undergoing HD were excluded in this study.

TMVR with MitraClip is indicated for patients with either functional or degenerative MR who are very high-risk surgical candidates (class IIb) according to European Society of Cardiology guidelines.[7] In the USA, the procedure is recommended only for patients with severe degenerative MR who are contraindicated for surgery, and are class IIb risk according to American Heart Association/ American College of Cardiology guidelines.[8]

Although recently, TMVR with MitraClip is more widely and frequently performed, the efficacy and safety of this procedure in HD patients has not been established to date.

Doshi et al compared the efficacy and safety of TMVR with that of surgical mitral valve replacement (SMVR) in patients with chronic kidney disease stage IV, Stage V, and end-stage renal disease.[9] They concluded that TMVR is associated with significantly lower in-hospital morbidity and mortality, with significant cost savings in patients with advanced kidney disease compared with SMVR. On the other hand, Kaneko et al reported that severe CKD (eGFR <30 mL/min/1.73 m2) was associated with higher mortality after MitraClip.[10] Estévez-Loureiro et al also reported that patients with creatinine clearance (CCl) <30 mL/min had higher rates of mortality and readmission at 16.2 ± 11.1 months of follow-up.[11] However, these studies excluded HD patients.

The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry Report surveyed 2952 patients commercially treated by TMVR with MitraClip in the USA between November 2013 and September 2015, among whom 4.1% of the patients were dialysis dependent.[12] In their study, dialysis was reported as a risk factor for mortality or re-hospitalization for heart failure within one year, as assessed by multivariate analysis.

However, there are few case reports describing the complications of MitraClip in HD patients. As an early complication, endocarditis one 1 month following MitraClip in an HD patient with an indwelling catheter has been reported.[13] That patient had Staphylococcus bacteremia, and transesophageal echocardiography demonstrated adhesions due to vegetation on the MitraClip. HD and the indwelling catheter might have increased the risk of blood stream infection in this case. As a late complication, the onset of severe calcific mitral stenosis 28 months after the MitraClip procedure in an HD patient has been reported.[14] In that case, significant calcification around the MitraClip was observed during subsequent MV surgery. The author noted that dystrophic calcification due to derangement of calcium and phosphate metabolism in HD patients might increase the risk of calcific stenosis.

In summary, although TMVR with MitraClip is a good treatment in HD patients who cannot undergo surgical treatment, the safety and efficacy of TMVR with MitraClip in HD patients have not been established to date; therefore, further studies in this field are warranted.

   Conclusion Top

Although TMVR with MitraClip was safe and effective in this case, further studies of this procedure in MitraClip patients are warranted. We must pay attention to both early and late-onset complications following this procedure.

   Ethics Approval and Consent to Participate Top

This study was performed in accordance with the principles of the Declaration of Helsinki. Consent to publish the patient’s clinical information was obtained from the patient.

Conflict of interest: None declared.

   References Top

Mirabel M, Iung B, Baron G, et al. What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery? Eur Heart J 2007;28:1358-65.  Back to cited text no. 1
Mo A, Tao Z, Feng Z, Yang X, Wu J. Mitral valve replacement in a dialysis-dependent patient. Ann Transl Med 2016;4:310.  Back to cited text no. 2
Horst M, Mehlhorn U, Hoerstrup SP, Suedkamp M, de Vivie ER. Cardiac surgery in patients with end-stage renal disease: 10-year experience. Ann Thorac Surg 2000;69:96-101.  Back to cited text no. 3
Alfieri O, Maisano F, De Bonis M, et al. The double-orifice technique in mitral valve repair: A simple solution for complex problems. J Thorac Cardiovasc Surg 2001;122:674-81.  Back to cited text no. 4
Maisano F, Torracca L, Oppizzi M, et al. The edge-to-edge technique: A simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg 1998;13:240-5.  Back to cited text no. 5
Feldman T, Kar S, Elmariah S, et al. Randomized Comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol 2015;66:2844-54.  Back to cited text no. 6
Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2017;38: 2739-91.  Back to cited text no. 7
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:2440-92.  Back to cited text no. 8
Doshi R, Shlofmitz E, Shah J, Meraj P. Comparison of transcatheter mitral valve repair versus surgical mitral valve repair in patients with advanced kidney disease (from the national inpatient sample). Am J Cardiol 2018; 121:762-7.  Back to cited text no. 9
Kaneko H, Neuss M, Schau T, Weissenborn J, Butter C. Interaction between renal function and percutaneous edge-to-edge mitral valve repair using MitraClip. J Cardiol 2017;69:476-82.  Back to cited text no. 10
Estévez-Loureiro R, Settergren M, Pighi M, et al. Effect of advanced chronic kidney disease in clinical and echocardiographic outcomes of patients treated with MitraClip system. Int J Cardiol 2015;198:75-80.  Back to cited text no. 11
Sorajja P, Vemulapalli S, Feldman T, et al. Outcomes with transcatheter mitral valve repair in the United States: An STS/ACC TVT registry report. J Am Coll Cardiol 2017;70: 2315-27.  Back to cited text no. 12
Rambhujun V, Kennedy-Snodgrass C, Kerwin T. Early endocarditis following percutaneous mitral repair in a dialysis patient. J Cardiovasc Dis Diagn 2018;6:14-6.  Back to cited text no. 13
Burgess A, Shah K, Hough O, Hynynen K. Late calcific mitral stenosis after mitraclip procedure in a dialysis-dependent patient. HHS Public Access 2016;15:477-91.  Back to cited text no. 14

Correspondence Address:
Tsutomu Sakurada
Department of Internal Medicine, Division of Nephrology and Hypertension, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa 216-8511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.344769

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