International Journal of Cardiology 185 (2015) 165–166
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiac arrest saves a patient's procedure Johannes Patzelt a, Peter Seizer a, Tobias Walker b, Axel Bauer a, Meinrad Gawaz a, Juergen Schreieck a, Harald F. Langer a,⁎ a b
University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany University Hospital, Department of Cardiovascular Surgery, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
a r t i c l e
i n f o
Article history: Received 31 January 2015 Accepted 7 March 2015 Available online 11 March 2015 Keywords: MitraClip Mitral valve regurgitation Cardiac arrest
A 68-year-old woman presented at our emergency department because of decompensated heart failure with anasarka. Recently, she had multiple hospitalizations due to cardiac decompensation. The patient had known chronic heart failure caused by ischemic heart disease with a moderately impaired left ventricular function. Furthermore, a severe tricuspid regurgitation had been treated by tricuspid valve reconstruction and annuloplasty 6 years ago, and she had undergone dual chamber pacemaker implantation with epicardial leads due to AV block grade III. Her cardiovascular risk factors included arterial hypertension, diabetes mellitus type II, a positive family history for cardiovascular events and adipositas, and the patient had paroxysmal atrial fibrillation. Echocardiographic workup revealed a moderately impaired left ventricular systolic function (ejection fraction 40%) and grade IV mitral valve regurgitation. The mitral valve regurgitation was of mixed genesis with a broad central jet and a flail leaflet of the PML (Fig. 1A, B, C, supplemental movie 1). As recompensation of the patient by treatment with diuretics was not sufficient, decision for percutaneous mitral valve repair was made by our heart team. During the intervention, grasping of the posterior leaflet of the mitral valve was not possible and numerous tries were not successful. Thus, we decided to make use of the missing ventricular escape rhythm in this particular patient. We induced asystole by turning off the pacemaker (via the programmer's check for spontaneous heart rhythm function, Medtronic ⁎ Corresponding author at: Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Otfried-Mueller-Straße 10, 72076 Tuebingen, Germany. E-mail address: [email protected] (H.F. Langer).
http://dx.doi.org/10.1016/j.ijcard.2015.03.128 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
device). In this situation, asystole with resulting cardiac arrest due to a pause N20 s preceding the ventricular escape rhythm gave us sufficient time to load both leaflets onto the clip arms (Fig. 1D, supplemental movie 2), and closure of the mitral valve resulted in correct position of the device with sufficient reduction of mitral regurgitation (Fig. 1E). Already during closure of the clip system, the ventricular pacing was reinitiated resulting in immediate proper contraction of the heart. Percutaneous mitral valve repair (PMVR) using the MitraClip system is an innovative method allowing for treatment of mitral regurgitation (MR) including patients who are not eligible for conventional heart surgery [1]. The advantage of the percutaneous approach over conventional surgery is the procedure being performed without any major injuries and no need for extracorporal circulation [2]. There are, however, also considerable disadvantages such as the indirect manipulation of the clip over the long distance of the clip delivery device causing difficult steerability and in some cases even failure to deliver the clip. For instance, severely impaired coaptation of the valve leaflets due to functional or degenerative shortening of the posterior leaflet is a major factor determining the feasibility of the procedure [3]. Thus, it is essential to place the clip into a perfect position catching as much material of the posterior mitral leaflet (PML) and the anterior mitral leaflet (AML) as possible. In the normal case of a beating heart, grasping both leaflets can be very challenging in some cases. Here, we report a case of PMVR in a pacemaker dependent patient, where only induction of asystole by turning off the pacemaker enabled us to grasp both leaflets of the mitral valve resulting in a sufficient reduction of MR. In cases with challenging anatomy and/or difficult clinical circumstances in these patients with serious comorbidities, prolonged time for clip delivery is desirable to allow for the optimal positioning of the clip and – as a consequence – an improved reduction of MR. In our case, asystole was achieved in a pacemaker-dependent patient by temporarily switching off stimulation in the absence of a ventricular escape rhythm in this particular patient. To our knowledge, this is the first report applying this maneuver in PMVR to achieve the best position of the clip. There may be other possibilities to further improve this novel and promising tool of interventional mitral valve reconstruction technique. Recently, we used left atrial intracardiac echocardiography (ICE) in addition to conventional transesophageal echocardiography (TEE) to visualize the steps of the procedure [4]. It may also be possible to make use of techniques to adjust inspiration and expiration during general anesthesia to improve clip positioning. Furthermore, rhythm control by intravenous medical treatment could be helpful in some cases. In this case, we show that temporary asystole with resulting cardiac arrest facilitates
166
J. Patzelt et al. / International Journal of Cardiology 185 (2015) 165–166
A
B
C
D
**
*
E
Fig. 1. (A) TEE: Initial finding with severe mitral regurgitation with broad vena contracta (X-Plane view with 2 orthogonal planes; left: intercommisural view, right: LVOT-view). (B) Morphology of the mitral valve with flail leaflet of the PML, four chamber view, → indicates the flail leaflet of the PML (C) X-Plane view with 2 orthogonal planes; left: intercommisural view, right: LVOT-view. → indicates the flail leaflet of the PML; see also supplemental movie 1. (D) Posterior mitral leaflet (PML **) and anterior mitral leaflet (AML *) are loaded onto the clip arms during asystole; see also supplemental movie 2. (E) MR result after implantation of 2 clips with residual MI I–II° (eccentric jet).
positioning of the clip. In patients without pacemaker, asystole may also be provoked by intravenous adenosine-bolus or via rapid ventricular pacing by a temporary pacemaker. Taken together, the positive outcomes in patients with PMVR of severe MR result in expansion of this approach to treat patients with MR and significant comorbidities. Therefore, we should carry on identifying tools to further improve this promising interventional therapy. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.03.128. Conflict of interest J. Schreieck has received speaker fees from Medtronic and St. Jude Medical.
References [1] T. Feldman, E. Foster, D.D. Glower, S. Kar, M.J. Rinaldi, P.S. Fail, R.W. Smalling, R. Siegel, G.A. Rose, E. Engeron, C. Loghin, A. Trento, E.R. Skipper, T. Fudge, G.V. Letsou, J.M. Massaro, L. Mauri, EVEREST II Investigators, Percutaneous repair or surgery for mitral regurgitation, N. Engl. J. Med. 364 (2011) 1395–1406. [2] R. Beigel, N.C. Wunderlich, S. Kar, et al., The evolution of percutaneous mitral valve repair therapy: lessons learned and implications for patient selection, J. Am. Coll. Cardiol. 64 (2014) 2688–2700. [3] G. Nickenig, R. Estevez-Loureiro, O. Franzen, et al., Percutaneous mitral valve edge-toedge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011– 2012 Pilot European Sentinel Registry, J. Am. Coll. Cardiol. 64 (2014) 875–884. [4] A. Henning, I.I. Mueller, K. Mueller, et al., Percutaneous edge-to-edge mitral valve repair escorted by left atrial intracardiac echocardiography (ICE), Circulation 130 (2014) e173–e174.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Cardiac arrest saves a patient's procedure Johannes Patzelt a, Peter Seizer a, Tobias Walker b, Axel Bauer a, Meinrad Gawaz a, Juergen Schreieck a, Harald F. Langer a,⁎ a b
University Hospital, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany University Hospital, Department of Cardiovascular Surgery, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
a r t i c l e
i n f o
Article history: Received 31 January 2015 Accepted 7 March 2015 Available online 11 March 2015 Keywords: MitraClip Mitral valve regurgitation Cardiac arrest
A 68-year-old woman presented at our emergency department because of decompensated heart failure with anasarka. Recently, she had multiple hospitalizations due to cardiac decompensation. The patient had known chronic heart failure caused by ischemic heart disease with a moderately impaired left ventricular function. Furthermore, a severe tricuspid regurgitation had been treated by tricuspid valve reconstruction and annuloplasty 6 years ago, and she had undergone dual chamber pacemaker implantation with epicardial leads due to AV block grade III. Her cardiovascular risk factors included arterial hypertension, diabetes mellitus type II, a positive family history for cardiovascular events and adipositas, and the patient had paroxysmal atrial fibrillation. Echocardiographic workup revealed a moderately impaired left ventricular systolic function (ejection fraction 40%) and grade IV mitral valve regurgitation. The mitral valve regurgitation was of mixed genesis with a broad central jet and a flail leaflet of the PML (Fig. 1A, B, C, supplemental movie 1). As recompensation of the patient by treatment with diuretics was not sufficient, decision for percutaneous mitral valve repair was made by our heart team. During the intervention, grasping of the posterior leaflet of the mitral valve was not possible and numerous tries were not successful. Thus, we decided to make use of the missing ventricular escape rhythm in this particular patient. We induced asystole by turning off the pacemaker (via the programmer's check for spontaneous heart rhythm function, Medtronic ⁎ Corresponding author at: Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Otfried-Mueller-Straße 10, 72076 Tuebingen, Germany. E-mail address: [email protected] (H.F. Langer).
http://dx.doi.org/10.1016/j.ijcard.2015.03.128 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
device). In this situation, asystole with resulting cardiac arrest due to a pause N20 s preceding the ventricular escape rhythm gave us sufficient time to load both leaflets onto the clip arms (Fig. 1D, supplemental movie 2), and closure of the mitral valve resulted in correct position of the device with sufficient reduction of mitral regurgitation (Fig. 1E). Already during closure of the clip system, the ventricular pacing was reinitiated resulting in immediate proper contraction of the heart. Percutaneous mitral valve repair (PMVR) using the MitraClip system is an innovative method allowing for treatment of mitral regurgitation (MR) including patients who are not eligible for conventional heart surgery [1]. The advantage of the percutaneous approach over conventional surgery is the procedure being performed without any major injuries and no need for extracorporal circulation [2]. There are, however, also considerable disadvantages such as the indirect manipulation of the clip over the long distance of the clip delivery device causing difficult steerability and in some cases even failure to deliver the clip. For instance, severely impaired coaptation of the valve leaflets due to functional or degenerative shortening of the posterior leaflet is a major factor determining the feasibility of the procedure [3]. Thus, it is essential to place the clip into a perfect position catching as much material of the posterior mitral leaflet (PML) and the anterior mitral leaflet (AML) as possible. In the normal case of a beating heart, grasping both leaflets can be very challenging in some cases. Here, we report a case of PMVR in a pacemaker dependent patient, where only induction of asystole by turning off the pacemaker enabled us to grasp both leaflets of the mitral valve resulting in a sufficient reduction of MR. In cases with challenging anatomy and/or difficult clinical circumstances in these patients with serious comorbidities, prolonged time for clip delivery is desirable to allow for the optimal positioning of the clip and – as a consequence – an improved reduction of MR. In our case, asystole was achieved in a pacemaker-dependent patient by temporarily switching off stimulation in the absence of a ventricular escape rhythm in this particular patient. To our knowledge, this is the first report applying this maneuver in PMVR to achieve the best position of the clip. There may be other possibilities to further improve this novel and promising tool of interventional mitral valve reconstruction technique. Recently, we used left atrial intracardiac echocardiography (ICE) in addition to conventional transesophageal echocardiography (TEE) to visualize the steps of the procedure [4]. It may also be possible to make use of techniques to adjust inspiration and expiration during general anesthesia to improve clip positioning. Furthermore, rhythm control by intravenous medical treatment could be helpful in some cases. In this case, we show that temporary asystole with resulting cardiac arrest facilitates
166
J. Patzelt et al. / International Journal of Cardiology 185 (2015) 165–166
A
B
C
D
**
*
E
Fig. 1. (A) TEE: Initial finding with severe mitral regurgitation with broad vena contracta (X-Plane view with 2 orthogonal planes; left: intercommisural view, right: LVOT-view). (B) Morphology of the mitral valve with flail leaflet of the PML, four chamber view, → indicates the flail leaflet of the PML (C) X-Plane view with 2 orthogonal planes; left: intercommisural view, right: LVOT-view. → indicates the flail leaflet of the PML; see also supplemental movie 1. (D) Posterior mitral leaflet (PML **) and anterior mitral leaflet (AML *) are loaded onto the clip arms during asystole; see also supplemental movie 2. (E) MR result after implantation of 2 clips with residual MI I–II° (eccentric jet).
positioning of the clip. In patients without pacemaker, asystole may also be provoked by intravenous adenosine-bolus or via rapid ventricular pacing by a temporary pacemaker. Taken together, the positive outcomes in patients with PMVR of severe MR result in expansion of this approach to treat patients with MR and significant comorbidities. Therefore, we should carry on identifying tools to further improve this promising interventional therapy. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2015.03.128. Conflict of interest J. Schreieck has received speaker fees from Medtronic and St. Jude Medical.
References [1] T. Feldman, E. Foster, D.D. Glower, S. Kar, M.J. Rinaldi, P.S. Fail, R.W. Smalling, R. Siegel, G.A. Rose, E. Engeron, C. Loghin, A. Trento, E.R. Skipper, T. Fudge, G.V. Letsou, J.M. Massaro, L. Mauri, EVEREST II Investigators, Percutaneous repair or surgery for mitral regurgitation, N. Engl. J. Med. 364 (2011) 1395–1406. [2] R. Beigel, N.C. Wunderlich, S. Kar, et al., The evolution of percutaneous mitral valve repair therapy: lessons learned and implications for patient selection, J. Am. Coll. Cardiol. 64 (2014) 2688–2700. [3] G. Nickenig, R. Estevez-Loureiro, O. Franzen, et al., Percutaneous mitral valve edge-toedge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011– 2012 Pilot European Sentinel Registry, J. Am. Coll. Cardiol. 64 (2014) 875–884. [4] A. Henning, I.I. Mueller, K. Mueller, et al., Percutaneous edge-to-edge mitral valve repair escorted by left atrial intracardiac echocardiography (ICE), Circulation 130 (2014) e173–e174.
