Mitral valve pressure gradient after percutaneous mitral valve repair: every beat counts

Abstract

A patient presented with symptoms of decompensated heart failure 2 months after percutaneous mitral valve (MV) repair. Echocardiography demonstrated impaired left ventricular function with elevated MV pressure gradients and pulmonary pressures during rapid atrial fibrillation. Heart rate control was achieved by implantation of a biventricular pacemaker with subsequent His‐bundle ablation because atrial fibrillation was refractory to medical treatment. During biventricular pacing at different rates (50–110 b.p.m.), heart rate correlated positively with both MV mean pressure gradient and global longitudinal strain and negatively with stroke volume. MV pressure gradients directly translated into elevated pulmonary pressures. Thus, rate control and biventricular pacing improved cardiac haemodynamics.

Gradient over Melody valve in left AV valve position reduces with beta blockade

“…The gradient over it, as in artificial mitral valves or after percutaneous valve repair, seems dependent on heart rate, as filling of the ventricle occurs over a shorter time interval. 6 Even though the valve itself in a Melody is a bovine jugular valve, the stent acts as a fixed valve annulus, comparable to mechanical valves. An increase in echocardiographic Doppler-derived gradients maybe interpreted as progressive stenosis.…”

Mitral valve interventions in heart failure

“…The principle of MitraClip is based on Alfieri's edge‐to‐edge repair, where the anterior and the posterior leaflets are grasped and attached at the location of the regurgitation jet, thus creating a double orifice MV . Several clips can be implanted until the regurgitation is sufficiently reduced, but MV orifice area during diastole has to be monitored carefully during the procedure because elevated mitral gradients after TMVR are associated with adverse outcome . The edge‐to‐edge repair technique is a symptomatic therapy because the mechanism, either leaflet tethering or annulus dilatation, is not targeted.…”

“…[18][19][20] Several clips can be implanted until the regurgitation is sufficiently reduced, but MV orifice area during diastole has to be monitored carefully during the procedure because elevated mitral gradients after TMVR are associated with adverse outcome. 21,22 The edge-to-edge repair technique is a symptomatic therapy because the mechanism, either leaflet tethering or annulus dilatation, is not targeted.…”

Impact of simulated MitraClip on forward flow obstruction in the setting of mitral leaflet tethering: An in vitro investigation

“…MitraClip patients with post-procedural moderate MS (mean MVG 5 mmHg), where the overall rate of moderate MS among patients treated with MitraClip was found to be 25% [4,5]. In FMR patients in particular, MS severity after MitraClip may be further exacerbated by diastolic restriction of the anterior mitral leaflet (AML) caused by severe dilatation of the left ventricle (LV) and papillary muscle (PM) displacement [6].…”

“…In many cases, multiple MitraClip devices are used to treat MR , though placement of additional devices can further reduce mitral valve area (MVA) and increase of mean mitral valve gradient (MVG), leading to mitral stenosis (MS) . Deteriorated long‐term outcomes have been recently demonstrated in MitraClip patients with post‐procedural moderate MS (mean MVG ≥ 5 mmHg), where the overall rate of moderate MS among patients treated with MitraClip was found to be 25% . In FMR patients in particular, MS severity after MitraClip may be further exacerbated by diastolic restriction of the anterior mitral leaflet (AML) caused by severe dilatation of the left ventricle (LV) and papillary muscle (PM) displacement .…”