Introduction: The development of percutaneous edge-to-edge techniques of mitral valve repair, such as the MitraClip device, has evolved as an efficient alternative non-surgical treatment for patients with symptomatic mitral regurgitation who were judged inoperable by a Heart Team.
Case presentation: T his is the case of a 80-year-old man with a history of myelodysplastic syndrome (the last bone marrow biopsy which was done 2 years ago showed normocellular marrow with neutropenia and thrombocytopenia with intermediate IPSS risk score), chronic infection with HCV and recently diagnosed severe mitral regurgitation; 3 weeks prior to the current admission, the patient was hospitalised bronchopneumonia and treated with iv vancomycin and meropenem.
The patient was admitted with signs and symptoms of congestive heart failure (shortness of breath on exertion and paroxysmal nocturnal dyspnea) with worsening symptoms in the last month. Physical examination revealed tachycardia, normal blood pressure and pulmo-nary bilateral crackles; the patient had no fever and no signs of systemic congestion. The patient also presented with purple, pruriginous spots on both legs, raising the suspicion of purpura. Initial blood tests asserted infla-matory syndrome (CRP 53 mg/dl), mild anemia with leucopenia (950/mm3) and thrombocytopenia (45000/ mm3) and markedly elevated brain natriuretic peptides (BNP 2965 pg/ml); normal renal function.
Echocardiography showed nondilated left ventricle with normal systolic function and severe mitral regur-gitation with eccentric jet towards the posterior wall of the left atrium and prolapse of the anterior leaflet with possible flail of the A2 scallop; an echo dense, mobile structure was observed attached to the anterior leaflet. The right ventricle had preserved function; severe tricuspid regurgitation with secondary pulmonary hypertension (PAPs of 70 mmHg). Transesophageal echocardiography confirmed the severe mitral regurgitation with prolapse of both mitral leaflets and flail of the A2 scallop; structure was interpreted as an old vegetation. Blood cultures were negative, and the determination of procalcitonin and presepsin infirmed sepsis.Vasculitic etiology of the purpura, including cryoglobulinemia, was excluded.Considering the fact that the patient had symptomatic mitral regurgitation and was considered inoperable, we decided for the transcatheter edge-to-edge mitral valve repair, which was performed using 3 MitraClip devices placed under angiographic and echocardiographic guidance; the residual mitral regur-gitation after the procedure was mild, no postoperati-ve complication. One month follow-up of the patient showed increased capacity of exertion with no clinical signs of congestive heart failure and a BNP of 356 pg/ ml. Echocardiography was performed in order to asses the correct position of the 3 MitraClip Devices; mild residual mitral regurgitation with low transvalvular gradients (6/2 mmHg) and normal systolic function of both ventricles with decreased pulmonary hypertensi-on (estimated PAPs of 47 mmHg).
Conclusion: Percutaneous edge-to-edge mitral valve repair could be an efficient solution for patients consi-dered inoperable by a Heart Team, with a positive im-pact on the quality of life for these patients.