The transcatheter deployment of the Amplatzer Duct Occluder II plug (ADO II; St Jude Medical) effectively reduced residual commissural mitral regurgitation after a MitraClip implantation, according to recent data published in JACC: Cardiovascular Interventions.

The MitraClip procedure is a transcatheter treatment option for patients with a high surgical risk with severe mitral regurgitation, but it is still difficult to manage residual mitral regurgitation after the implantation. However, a previous case report showed successful management between clips by transcatheter deployment of the device, prompting researchers to test the strategy, efficacy, and potential complications of this technique using ADO II.

They conducted a case series that included 9 consecutive patients (mean age: 79.3 ± 11.4 years) who underwent ADO II transcatheter deployment between April and October 2015. Most patients (88.9%) had a New York Heart Association (NYHA) functional class of III or IV, and the initial mitral regurgitation etiology was degenerative in 6 patients, functional in 2 patients, and mixed in 1 patient.


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“When residual MR [mitral regurgitation] is treated after the first clip implantation, the second clip should be delivered and implanted parallel to the first clip to grasp the maximum amount of leaflet tissue,” the authors wrote.

“However, in some cases with more complex mitral valve anatomy and morphology, residual MR cannot be treated completely using multiple clips, and residual jets are left between the clips. Because additional clip implantation can interfere with the existing clips, transcatheter occluder device deployment would be an attractive solution for these intraclip jets.”

The ADO II plug deployment was performed during the initial MitraClip procedure in 7 patients, and during a second procedure for recurrent heart failure symptoms in 2 patients. After the MitraClip procedure, researchers observed residual commissural mitral regurgitation in 3 patients and residual intraclip mitral regurgitation in 6 patients.

ADO II was deployed successfully in all patients, each of whom had significantly reduced mitral regurgitation and left atrial pressure. However, the device was retrieved in 1 patient due to device embolization in the ostial right coronary artery.

All patients were discharged 1.8 ± 1.2 days after the procedure with no significant mitral regurgitation on the pre-discharge transthoracic echocardiography. Among the 8 patients who underwent a 1-month follow-up symptom assessment, all had clinical symptoms in the NYHA functional class I or II.

“Importantly, device deployment did not affect the mitral valve pressure gradient,” the authors wrote. “This technique should be considered to treat anatomically challenging high-risk cases using the MitraClip procedure.”

The authors noted that a longer follow-up observation with a larger cohort is necessary to confirm the long-term efficacy and safety of the transcatheter procedure.

Reference

Kubo S, Cox JM, Mizutani Y, et al. Transcatheter procedure for residual regurgitation after MitraClip Implantation Using Amplatzer Duct Occluder II. JACC Cardiovasc Interv. 2016;9(12):1280-1288. doi: 10.1016/j.jcin.2016.03.011.