Catheterization and Cardiovascular Interventions 86:E107–E110 (2015)
Restoration of Normal Left Ventricular Geometry after Percutaneous Mitral Annuloplasty: Case Report and Review of Literature Muhammad Adil Soofi,*
FCPS, MRCP
and Faisal Alsamadi,
MD, FRCPC
Surgical mitral valve intervention is not considered suitable in patients with severe functional mitral regurgitation due to severe dilated cardiomyopathy and severe systolic dysfunction. In such patients percutaneous mitral valve intervention is the next best alternative. We are presenting case report of a patient who presented with severe dyspnea progressing to orthopnea and paroxysmal nocturnal dyspnea. He was found to have severe functional mitral regurgitation and severe left ventricle systolic dysfunction. Surgical mitral intervention was not considered suitable and percutaneous mitral annuloplasty was done. At one month follow-up significant improvement in symptoms were noted with improvement in severity of mitral regurgitation severity. At 6 months follow-up further improvement in symptoms were noted along with significant improvement in the severity of mitral regurgitation and normalization of left ventricle geometry. At 1 year follow-up his symptoms further improved, left ventricle geometry remained normal and mitral regurgitation severity remained mild to moderate. Our case demonstrate that in patient with severe LV systolic dysfunction, severe mitral regurgitation and left bundle branch block percutaneous mitral annuloplasty can obviate the need for CRT-D due to significant improvement in LV function and geometry along with regression in severity of mitral regurgitation. Improvement in mitral regurgitation severity and LV geometry started early and kept improving with excellent result at 6 and 12 months. VC 2014 Wiley Periodicals, Inc. Key words: severe mitral regurgitation; severe left ventricle dysfunction; percutaneous mitral annuloplasty
INTRODUCTION
In patients with severe cardiomyopathy, mitral regurgitation contributes to worsening of symptoms and progressive adverse remodeling of left ventricle (LV). [1,2] Annuloplasty is the mainstay of surgery in patients with functional mitral regurgitation. In patients who are not considered for surgical intervention; percutaneous mitral annuloplasty is alternative. We are presenting the case report of a successful indirect mitral annuloplasty by placing Carillon device in the coronary sinus/great cardiac vein of a patient with severe cardiomyopathy, severe mitral regurgitation and left bundle branch block (LBBB). The patient had a dramatic improvement in symptoms and near normalization of LV function with significant regression of mitral regurgitation at 6 months follow-up. Her symptoms continued to improve with improvement in left ventricular geometry at 1 year follow-up.
with deteriorating dyspnea progressing to New York Heart Association (NYHA) class III-IV over the last 2 months and was found to be in decompensated congestive cardiac failure. Her electrocardiogram was consistent with LBBB pattern and echo showed dilated cardiac chambers, severe left ventricular systolic dysfunction, malcoaptation of mitral leaflets, severe mitral regurgitation (Fig. 1), severe tricuspid regurgitation, and moderate to severe pulmonary hypertension. Her blood pressure was 103/78 mm Hg, pulse 92/min and cardiovascular examination revealed a pansystolic Prince Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia Conflict of interest: Nothing to report. *Correspondence to: Dr. Muhammad Adil Soofi, FCPS, MRCP, Assistant Consultant Cardiology, Prince Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]
CASE REPORT
Received 11 February 2014; Revision accepted 22 September 2014
Fifty-three years old diabetic lady had percutaneous coronary intervention of left anterior descending artery (LAD) in 2010. She presented after 2 years in 2012
DOI: 10.1002/ccd.25689 Published online 7 October 2014 in Wiley Online Library (wileyonlinelibrary.com)
C 2014 Wiley Periodicals, Inc. V
E108
Soofi and AlSamadi
Fig. 1. Dimensions and severity of mitral regurgitation before the Carillon implantation. (A) Dilated Left ventricle during systole and diastole. (B) Dilated Left atrium dimension. (C) Mitral inflow Pulsed wave velocity showing grade III diastolic dysfunction. (D) Color Doppler in four chamber apical view showing severe mitral regurgitation. (E) Continuous flow Doppler across mitral valve showing dense and complete regurgitant jet consistent with severe mitral regurgitation. (F) Color Doppler in parasternal long axis view showing severe mitral regurgitation.
TABLE I. Comparison of Dyspnea Class, Dimension, and Function of Cardiac Chambers and Mitral Regurgitation Severity at Baseline and Follow-ups
NYHA class LA size E/A ratio LVIDs LVIDd EF Mitral regurgitation severity EROA Vena contracta Regurgitation volume Regurgitation fraction
Baseline
1 month follow up
6 months follow up
1 year follow up
IV 4.2 cm 2.12 5.5 cm 7.2 cm 20% 4
III 4.1 cm 1.25 5.1 cm 6.5 cm 30% 3
I 3.8 0.84 3.7 cm 5.1 cm 50% 2
I 3.7 1.1 3.7 cm 5.1 cm 55% 2
0.45 cm2 0.84 cm 91 ml 62%
0.3 cm2 0.7 cm 70 ml 52%
0.23 cm2 0.25 cm 29 ml 20%
0.2 cm2 0.25 cm 28 ml 20%
murmur at apex and lower sternal border consistent with mitral and tricuspid regurgitation, respectively. Severe mitral regurgitation was considered functional
due to dilated cardiac chambers and was not considered for surgical intervention. Her coronary angiogram showed severe focal in-stent restenosis of mid LAD stent and was treated with drug eluting balloon dilatation. She was planned for percutaneous mitral annuloplasty using the Carillon mitral repair device. Coronary venogram before the procedure showed that the left circumflex artery would not be compressed by Carillon device. Procedure was done under general anesthesia with fluoroscopic guidance. Coronary sinus (CS) was cannulated from the right internal jugular vein with a 9 French delivery catheter. To provide stable anchoring, a distal anchor; oversized relative to the venous dimension was deployed deep in the CS. Traction was then placed on the delivery system to plicate the periannular tissue. The degree of traction was guided by both fluoroscopic and echocardiographic assessments. Once tissue plication was optimized, the proximal anchor was deployed near
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Efficacy of Percutaneous Mitral Annuloplasty
E109
Fig. 2. Dimension of left ventricle and left atrium at 1 month after Carillon implantation. (A) M-mode across parasternal long axis view of Left ventricle showing dilated Left ventricle during systole and diastole. (B) M-mode showing dilated Left atrium.
Fig. 3. Dimensions and severity of mitral regurgitation after the Carillon implantation (follow-up at 1 year). (A) Normal sized left ventricle during systole and diastole. (B) Normal sized Left atrium. (C) Mitral inflow Pulsed wave velocity showing normal diastolic function. (D) Color Doppler in four cham-
ber apical view showing Mild mitral regurgitation. (E) Continuous flow Doppler across mitral valve showing partially complete and less dense regurgitant jet consistent with mild to moderate mitral regurgitation. (F) Color Doppler in parasternal long axis view showing mild mitral regurgitation.
the CS ostium. The Carillon device size used during the procedure was 11 18 60 mm. The patient was noted to have mild improvement in symptoms, mitral regurgitation severity, and LV sys-
tolic function at 1 month follow up (Table I) but there was no improvement in LV geometry (Fig. 2). At 6 months, there was significant improvement in symptoms and echo showed near normalization of LV
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
E110
Soofi and AlSamadi
systolic function and geometry (Fig. 3). Mitral regurgitation regressed to mild intensity (Fig. 3). She showed continued improvement in symptoms and preserved LV geometry even at 1 year follow up (Table I). She was continued on antiplatelets, beta blocker, angiotensin converting enzyme inhibitor (ACEI) and statin however loop and potassium sparing diuretics were stopped. DISCUSSION
Severe left ventricle systolic dysfunction is commonly associated with functional mitral regurgitation due to annular dilatation which contributes to progressive adverse remodeling and worsening symptoms [1,2]. Surgical annuloplasty has been shown to reduce NYHA and left ventricular dimensions, but typically in the context of surgical revascularization [3]. In patients deemed at risk for surgical intervention, application of percutaneous approaches including Mitraclip [4] and application of direct or indirect mitral annuloplasty have shown promising results. Cardiac resynchronization therapy (CRT) has been shown to cause reverse remodeling [5] and improve survival [6] in which the pacing reduces severity of mitral regurgitation, although it is not being considered the primary aim of the device and would be restricted in the selective group of patients having wide QRS complex. Percutaneous mitral annuloplasty can be done using direct retrograde approach through aorta and left ventricle or indirect approach through vena-cava, right atrium and placing device in the coronary sinus [7]. Coronary sinus parallels the posterior mitral leaflet and encircles about two-thirds of the mitral annulus. The obvious appeal of the coronary sinus approach is simplicity and ease of use. In our patient the Carillon device was implanted in the coronary sinus without any complication. She also fulfilled the criteria for cardiac resynchronization therapy with defibrillator (CRT-D) (NYHA III-IV, EF 15–20% and LBBB) but was not considered as the initial option because the CS lead of CRT-D would have been compressed if Carillon device was later needed for mitral regurgitation. Her symptoms started improving soon after the procedure along with the severity of mitral regurgitation, but LV dimensions did not improve (Fig. 2). Her symptoms continued to improve and echo at 6 months showed normalization of LV dimensions along with regression of mitral regurgitation to milder intensity. Her improvement in symptoms and LV geometry was attributed to reduction in mitral regurgitation severity, however, role of patent coronary artery cannot be underestimated as our patient also had the percutaneous coronary intervention of LAD. Reverse LV remodeling and regression of mitral regurgitation was not unique in
our patient, it was also reported in the TITAN trial [8] and improvement persisted up to 24 months. In our patient also improvement in symptoms, normal LV geometry and mild mitral regurgitation persisted at 1 year follow-up (Table I) (Fig. 3). Our case demonstrated that the improvement in mitral regurgitation and reverse remodeling of LV dimensions may not be achieved initially and one should not be hasty in placing CRT-D in such patients because the condition may improve further as happened in our case. CONCLUSION
In symptomatic patients with severe LV systolic dysfunction with severe mitral regurgitation and LBBB, CRT-D has been associated with improved survival but percutaneous mitral annuloplasty can obviate the need for such device due to significant improvement in LV function and geometry along with regression in severity of mitral regurgitation. Improvement in mitral regurgitation severity and LV geometry started early and kept improving with excellent result at 6 and 12 months. REFERENCES 1. Trichon BH, Felker GM, Shaw LK, Cabell CH, O’Connor CM. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction heart failure. Am J Cardiol 2003;91:538–543. 2. DiBiase L, Auricchio A, Mohanty P, Bai R, Kautzner J, Pieragnoli P, Regoli F, Sorgente A, Spinucci G, Ricciardi G, Michelucci A, Natale A. Impact of cardiac resynchronization therapy on the severity of mitral regurgitation. Europace 2011;13:829–838. 3. Fattouch K, Guccione F, Sampognaro R, Panzarella G, Corrado E, Navarra E, Calvaruso D, Ruvolo G. Efficacy of adding mitral valve restrictive annuloplasty t coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: A randomized trial. J Thorac Cardiovasc Surg 2009;138:278–285. 4. Franzen O, vanderHeyden J, Schluter Baldus, Schillinger W, Butter C, Hoffman R, Corti R, Pedrazzini G, Swaans MJ, Neuss M, Rudolf V, Surder D, Grunenfelder J, Eulenburg C, Reichenspurner H, Meinertz T, Auricchio A. Mitra Clip therapy in patients with end-stage heart failure. Eur J Heart Fail 2011;13:569–576. 5. Liang YJ, Zhang Q, Fung J, Chan JYS, Yip GWK, Lam YY, Yu CM. Impact of reduction in early and late systolic functional mitral regurgitation on reverse remodeling after cardiac resynchronization therapy. Eur Heart J 2010;31:2359–2368. 6. VanBommel RJ, Marsan NA, Delgado V, Borleffs CJW, van Rijinsoever EPM, Schalij MJ, Bax JJ. Cardiac resynchronization therapy as a therapeutic option in patients with moderate–Severe functional mitral regurgitation and high operative risk. Circulation 2011;124:912–919. 7. Feldman, Cilingiroglu M. Percutaneous leaflet repair and annuloplasty for mitral regurgitation. J Am Coll Cardiol 2011;57:529–537. 8. Siminiak T, Wu JC, Haude M, Hoppe UC, Sadowski J, Lipiecki JL, Fajadet J, Shah AM, Feldman T, Kay DM, Goldberg SL, Levy WC, Solomon SD, Reuter DG. Treatment of functional mitral regurgitation by percutaneous annuloplasty: Results of the TITAN trial. Eur J Heart Fail 2012;14: 931–938.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Restoration of Normal Left Ventricular Geometry after Percutaneous Mitral Annuloplasty: Case Report and Review of Literature Muhammad Adil Soofi,*
FCPS, MRCP
and Faisal Alsamadi,
MD, FRCPC
Surgical mitral valve intervention is not considered suitable in patients with severe functional mitral regurgitation due to severe dilated cardiomyopathy and severe systolic dysfunction. In such patients percutaneous mitral valve intervention is the next best alternative. We are presenting case report of a patient who presented with severe dyspnea progressing to orthopnea and paroxysmal nocturnal dyspnea. He was found to have severe functional mitral regurgitation and severe left ventricle systolic dysfunction. Surgical mitral intervention was not considered suitable and percutaneous mitral annuloplasty was done. At one month follow-up significant improvement in symptoms were noted with improvement in severity of mitral regurgitation severity. At 6 months follow-up further improvement in symptoms were noted along with significant improvement in the severity of mitral regurgitation and normalization of left ventricle geometry. At 1 year follow-up his symptoms further improved, left ventricle geometry remained normal and mitral regurgitation severity remained mild to moderate. Our case demonstrate that in patient with severe LV systolic dysfunction, severe mitral regurgitation and left bundle branch block percutaneous mitral annuloplasty can obviate the need for CRT-D due to significant improvement in LV function and geometry along with regression in severity of mitral regurgitation. Improvement in mitral regurgitation severity and LV geometry started early and kept improving with excellent result at 6 and 12 months. VC 2014 Wiley Periodicals, Inc. Key words: severe mitral regurgitation; severe left ventricle dysfunction; percutaneous mitral annuloplasty
INTRODUCTION
In patients with severe cardiomyopathy, mitral regurgitation contributes to worsening of symptoms and progressive adverse remodeling of left ventricle (LV). [1,2] Annuloplasty is the mainstay of surgery in patients with functional mitral regurgitation. In patients who are not considered for surgical intervention; percutaneous mitral annuloplasty is alternative. We are presenting the case report of a successful indirect mitral annuloplasty by placing Carillon device in the coronary sinus/great cardiac vein of a patient with severe cardiomyopathy, severe mitral regurgitation and left bundle branch block (LBBB). The patient had a dramatic improvement in symptoms and near normalization of LV function with significant regression of mitral regurgitation at 6 months follow-up. Her symptoms continued to improve with improvement in left ventricular geometry at 1 year follow-up.
with deteriorating dyspnea progressing to New York Heart Association (NYHA) class III-IV over the last 2 months and was found to be in decompensated congestive cardiac failure. Her electrocardiogram was consistent with LBBB pattern and echo showed dilated cardiac chambers, severe left ventricular systolic dysfunction, malcoaptation of mitral leaflets, severe mitral regurgitation (Fig. 1), severe tricuspid regurgitation, and moderate to severe pulmonary hypertension. Her blood pressure was 103/78 mm Hg, pulse 92/min and cardiovascular examination revealed a pansystolic Prince Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia Conflict of interest: Nothing to report. *Correspondence to: Dr. Muhammad Adil Soofi, FCPS, MRCP, Assistant Consultant Cardiology, Prince Salman Heart Center, King Fahad Medical City, Riyadh, Saudi Arabia. E-mail: [email protected]
CASE REPORT
Received 11 February 2014; Revision accepted 22 September 2014
Fifty-three years old diabetic lady had percutaneous coronary intervention of left anterior descending artery (LAD) in 2010. She presented after 2 years in 2012
DOI: 10.1002/ccd.25689 Published online 7 October 2014 in Wiley Online Library (wileyonlinelibrary.com)
C 2014 Wiley Periodicals, Inc. V
E108
Soofi and AlSamadi
Fig. 1. Dimensions and severity of mitral regurgitation before the Carillon implantation. (A) Dilated Left ventricle during systole and diastole. (B) Dilated Left atrium dimension. (C) Mitral inflow Pulsed wave velocity showing grade III diastolic dysfunction. (D) Color Doppler in four chamber apical view showing severe mitral regurgitation. (E) Continuous flow Doppler across mitral valve showing dense and complete regurgitant jet consistent with severe mitral regurgitation. (F) Color Doppler in parasternal long axis view showing severe mitral regurgitation.
TABLE I. Comparison of Dyspnea Class, Dimension, and Function of Cardiac Chambers and Mitral Regurgitation Severity at Baseline and Follow-ups
NYHA class LA size E/A ratio LVIDs LVIDd EF Mitral regurgitation severity EROA Vena contracta Regurgitation volume Regurgitation fraction
Baseline
1 month follow up
6 months follow up
1 year follow up
IV 4.2 cm 2.12 5.5 cm 7.2 cm 20% 4
III 4.1 cm 1.25 5.1 cm 6.5 cm 30% 3
I 3.8 0.84 3.7 cm 5.1 cm 50% 2
I 3.7 1.1 3.7 cm 5.1 cm 55% 2
0.45 cm2 0.84 cm 91 ml 62%
0.3 cm2 0.7 cm 70 ml 52%
0.23 cm2 0.25 cm 29 ml 20%
0.2 cm2 0.25 cm 28 ml 20%
murmur at apex and lower sternal border consistent with mitral and tricuspid regurgitation, respectively. Severe mitral regurgitation was considered functional
due to dilated cardiac chambers and was not considered for surgical intervention. Her coronary angiogram showed severe focal in-stent restenosis of mid LAD stent and was treated with drug eluting balloon dilatation. She was planned for percutaneous mitral annuloplasty using the Carillon mitral repair device. Coronary venogram before the procedure showed that the left circumflex artery would not be compressed by Carillon device. Procedure was done under general anesthesia with fluoroscopic guidance. Coronary sinus (CS) was cannulated from the right internal jugular vein with a 9 French delivery catheter. To provide stable anchoring, a distal anchor; oversized relative to the venous dimension was deployed deep in the CS. Traction was then placed on the delivery system to plicate the periannular tissue. The degree of traction was guided by both fluoroscopic and echocardiographic assessments. Once tissue plication was optimized, the proximal anchor was deployed near
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Efficacy of Percutaneous Mitral Annuloplasty
E109
Fig. 2. Dimension of left ventricle and left atrium at 1 month after Carillon implantation. (A) M-mode across parasternal long axis view of Left ventricle showing dilated Left ventricle during systole and diastole. (B) M-mode showing dilated Left atrium.
Fig. 3. Dimensions and severity of mitral regurgitation after the Carillon implantation (follow-up at 1 year). (A) Normal sized left ventricle during systole and diastole. (B) Normal sized Left atrium. (C) Mitral inflow Pulsed wave velocity showing normal diastolic function. (D) Color Doppler in four cham-
ber apical view showing Mild mitral regurgitation. (E) Continuous flow Doppler across mitral valve showing partially complete and less dense regurgitant jet consistent with mild to moderate mitral regurgitation. (F) Color Doppler in parasternal long axis view showing mild mitral regurgitation.
the CS ostium. The Carillon device size used during the procedure was 11 18 60 mm. The patient was noted to have mild improvement in symptoms, mitral regurgitation severity, and LV sys-
tolic function at 1 month follow up (Table I) but there was no improvement in LV geometry (Fig. 2). At 6 months, there was significant improvement in symptoms and echo showed near normalization of LV
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
E110
Soofi and AlSamadi
systolic function and geometry (Fig. 3). Mitral regurgitation regressed to mild intensity (Fig. 3). She showed continued improvement in symptoms and preserved LV geometry even at 1 year follow up (Table I). She was continued on antiplatelets, beta blocker, angiotensin converting enzyme inhibitor (ACEI) and statin however loop and potassium sparing diuretics were stopped. DISCUSSION
Severe left ventricle systolic dysfunction is commonly associated with functional mitral regurgitation due to annular dilatation which contributes to progressive adverse remodeling and worsening symptoms [1,2]. Surgical annuloplasty has been shown to reduce NYHA and left ventricular dimensions, but typically in the context of surgical revascularization [3]. In patients deemed at risk for surgical intervention, application of percutaneous approaches including Mitraclip [4] and application of direct or indirect mitral annuloplasty have shown promising results. Cardiac resynchronization therapy (CRT) has been shown to cause reverse remodeling [5] and improve survival [6] in which the pacing reduces severity of mitral regurgitation, although it is not being considered the primary aim of the device and would be restricted in the selective group of patients having wide QRS complex. Percutaneous mitral annuloplasty can be done using direct retrograde approach through aorta and left ventricle or indirect approach through vena-cava, right atrium and placing device in the coronary sinus [7]. Coronary sinus parallels the posterior mitral leaflet and encircles about two-thirds of the mitral annulus. The obvious appeal of the coronary sinus approach is simplicity and ease of use. In our patient the Carillon device was implanted in the coronary sinus without any complication. She also fulfilled the criteria for cardiac resynchronization therapy with defibrillator (CRT-D) (NYHA III-IV, EF 15–20% and LBBB) but was not considered as the initial option because the CS lead of CRT-D would have been compressed if Carillon device was later needed for mitral regurgitation. Her symptoms started improving soon after the procedure along with the severity of mitral regurgitation, but LV dimensions did not improve (Fig. 2). Her symptoms continued to improve and echo at 6 months showed normalization of LV dimensions along with regression of mitral regurgitation to milder intensity. Her improvement in symptoms and LV geometry was attributed to reduction in mitral regurgitation severity, however, role of patent coronary artery cannot be underestimated as our patient also had the percutaneous coronary intervention of LAD. Reverse LV remodeling and regression of mitral regurgitation was not unique in
our patient, it was also reported in the TITAN trial [8] and improvement persisted up to 24 months. In our patient also improvement in symptoms, normal LV geometry and mild mitral regurgitation persisted at 1 year follow-up (Table I) (Fig. 3). Our case demonstrated that the improvement in mitral regurgitation and reverse remodeling of LV dimensions may not be achieved initially and one should not be hasty in placing CRT-D in such patients because the condition may improve further as happened in our case. CONCLUSION
In symptomatic patients with severe LV systolic dysfunction with severe mitral regurgitation and LBBB, CRT-D has been associated with improved survival but percutaneous mitral annuloplasty can obviate the need for such device due to significant improvement in LV function and geometry along with regression in severity of mitral regurgitation. Improvement in mitral regurgitation severity and LV geometry started early and kept improving with excellent result at 6 and 12 months. REFERENCES 1. Trichon BH, Felker GM, Shaw LK, Cabell CH, O’Connor CM. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction heart failure. Am J Cardiol 2003;91:538–543. 2. DiBiase L, Auricchio A, Mohanty P, Bai R, Kautzner J, Pieragnoli P, Regoli F, Sorgente A, Spinucci G, Ricciardi G, Michelucci A, Natale A. Impact of cardiac resynchronization therapy on the severity of mitral regurgitation. Europace 2011;13:829–838. 3. Fattouch K, Guccione F, Sampognaro R, Panzarella G, Corrado E, Navarra E, Calvaruso D, Ruvolo G. Efficacy of adding mitral valve restrictive annuloplasty t coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: A randomized trial. J Thorac Cardiovasc Surg 2009;138:278–285. 4. Franzen O, vanderHeyden J, Schluter Baldus, Schillinger W, Butter C, Hoffman R, Corti R, Pedrazzini G, Swaans MJ, Neuss M, Rudolf V, Surder D, Grunenfelder J, Eulenburg C, Reichenspurner H, Meinertz T, Auricchio A. Mitra Clip therapy in patients with end-stage heart failure. Eur J Heart Fail 2011;13:569–576. 5. Liang YJ, Zhang Q, Fung J, Chan JYS, Yip GWK, Lam YY, Yu CM. Impact of reduction in early and late systolic functional mitral regurgitation on reverse remodeling after cardiac resynchronization therapy. Eur Heart J 2010;31:2359–2368. 6. VanBommel RJ, Marsan NA, Delgado V, Borleffs CJW, van Rijinsoever EPM, Schalij MJ, Bax JJ. Cardiac resynchronization therapy as a therapeutic option in patients with moderate–Severe functional mitral regurgitation and high operative risk. Circulation 2011;124:912–919. 7. Feldman, Cilingiroglu M. Percutaneous leaflet repair and annuloplasty for mitral regurgitation. J Am Coll Cardiol 2011;57:529–537. 8. Siminiak T, Wu JC, Haude M, Hoppe UC, Sadowski J, Lipiecki JL, Fajadet J, Shah AM, Feldman T, Kay DM, Goldberg SL, Levy WC, Solomon SD, Reuter DG. Treatment of functional mitral regurgitation by percutaneous annuloplasty: Results of the TITAN trial. Eur J Heart Fail 2012;14: 931–938.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
