SAM and Severe Mitral Regurgitation Post-Acute Type A Aortic Dissection Surgery Treated With MitraClip

Bailout MitraClip therapy for deteriorated systolic anterior motion-related severe mitral regurgitation post-alcohol septal ablation: a case report

Background

Percutaneous alcohol septal ablation (ASA) is a non-surgical treatment for symptomatic hypertrophic obstructive cardiomyopathy. It has a potential risk for systolic anterior motion (SAM)-related mitral regurgitation (MR) deterioration, leading to acute congestive heart failure. In such clinical scenarios, additional surgical interventions for SAM-MR are risky.

Case summary

A 70-year-old man experienced acutely deteriorated heart failure caused by SAM-related MR following ASA, for which venous-arterial extracorporeal membrane oxygenation (ECMO) and a percutaneous left ventricular assist device (Impella CP, Abiomed, MA, USA) were required. Transoesophageal echocardiography showed that an interventricular septal oedematous protrusion led to a large coaptation gap of mitral leaflets with a pseudo-prolapse of the posterior mitral leaflet (PML). Because of his prohibitive surgical risks, we opted for transcatheter edge-to-edge mitral valve repair with MitraClip therapy. After removing the Impella device, an XT clip (Abbott Vascular, CA, USA) was located to cover the pseudo-prolapsed PML, resulting in optimal MR reduction with an acceptable mean transmitral valve-pressure gradient. Thereafter, his heart failure was well controlled, and venous-arterial ECMO was successfully removed on post-MitraClip Day 2.

Discussion

This case demonstrated that MitraClip therapy rescued the patient from a rare complication of severe acute heart failure with haemodynamic collapse caused by massive SAM-related MR following ASA. MitraClip therapy can be a feasible, less-invasive interventional therapy for SAM-related MR in cases with acceptable severity of iatrogenic mitral stenosis post-MitraClip implantation.

MitraClip used for severe mitral regurgitation after surgery for type A aortic dissection combined with Marfan syndrome

Mitral regurgitation is a rare but catastrophic condition in patients after surgery for type A aortic dissection. The second thoracotomy to complete the mitral valve operation could be fatal. Here, we report a case of severe mitral regurgitation treated with MitraClip in a 53-year-old woman after surgery for type A aortic dissection combined with Marfan syndrome. She was discharged uneventfully, and a significant reduction of regurgitation of mitral valve and tricuspid valve was observed at the 6-month follow-up. MitraClip could be an alternative device for such high-risk patients.

Treatment of severe acute mitral regurgitation following thoracoabdominal aortic aneurysm repair

An asymptomatic 63-year-old male with chronic type B aortic dissection underwent repair of an expanding 6.1 cm extent I thoracoabdominal aortic aneurysm. His postoperative course was complicated by respiratory failure from severe acute mitral regurgitation likely due to papillary muscle rupture, which was corrected with transcatheter MitraClip edge-to-edge repair.

Systolic anterior motion of the mitral valve associated with acute type A aortic dissection: a case report describing one-step surgery of ascending aortic replacement and interventricular septal myectomy

BACKGROUND

Systolic anterior motion of the mitral valve associated with acute type A aortic dissection is rare in daily clinical practice. The prevention of systolic anterior motion is important, because once it occurs, the hemodynamics may become unstable, leading to a critical situation. In the surgical procedure to treat systolic anterior motion, the prevention of new iatrogenic aortic intimal tears is important in the context of acute type A aortic dissection.

CASE PRESENTATION

We present a case of systolic anterior motion in a 68-year-old woman with an acute type A aortic dissection and suspected acute relative adrenal insufficiency. Preoperative transthoracic echocardiography revealed left ventricular outflow tract obstruction due to systolic anterior motion without left ventricular hypertrophy and interventricular septal bulging due to a narrow aorto-mitral angle. We successfully performed a one-step surgery for ascending aortic replacement and interventricular septal myectomy using the needle stick technique for the treatment of systolic anterior motion.

CONCLUSIONS

Concomitant interventricular septal myectomy using the needle stick technique with thoracic aortic replacement is a safe and feasible technique. Interventricular septal myectomy may be effective in preventing postoperative unstable hemodynamics due to systolic anterior motion in the management of acute aortic dissection.