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Archive for the ‘MVPS’ Category

Mitra clip is a small metal device that is delivered percutaneously, to clip the incompletely coapting (closing) mitral valve. It was first introduced to treat degenerative mitral regurgitation. It is an interventional imitation of the famous edge to edge Alfieri stitch repair.This procedure in fact converts the single mitral valve orifice into two. In the process, curtails the regurgitation jet orifice significantly. Though the technique looks nice and simple to hear, lots of per and post-procedure issues need refinement. Conceptually it is ideal in primary disorders of the mitral valve. (Read EVEREST 2 criteria for optimal patient selection)  There have been more than 60000 Mitra clips implanted worldwide wide. Thanks to Abbot.

In secondary MR (due to LV dysfunction) Mitra clip has shown mixed results( MITRA-FR not much benefit, COAPT -Did show benefits)

Now, what about Mitra clip as a remedy for rheumatic mitral regurgitation?

This is the question everyone likes to ask. Now we have some interesting breakthroughs. Dr. Ningyan Wong from the National University of Singapore reports probably the first case (Ref 1) . The videos are reproduced with the creative commons license.

 

Note the classical thickened AML in rheumatic mitral regurgitation.

 

 

TEE showing severe MR

 

Post Mitra clip : A real surprise to note near-total abolition of regurgitation. (This really is good news for the rheumatic mitral valves )

Technical issues

  • Should be isolated MR
  • P2/A2 scallop clipping is the key to success. 
  • The thickness of the leaflet limits the success (Grasping the leaflet will be difficult)
  • Clip Induced mitral stenosis is a distinct risk.

Potential role and future

RHD forms 90 % of valvular heart disease in a country like India. The incidence of Isolated MR in both acute rheumatic fever and chronic  RHD are substantial. If only we refine the hardware and technique to suit these thickened rheumatic valves, Mitra clip is expected to make an impact in this unique group of patients where surgery can be avoided or at least postponed

Though we would very much like to do such a trial in our place, logistics has effectively precluded it. I wish some large centers like AIIMS New Delhi or PGIMER Chandigarh and others can take this concept to the next level.  

 

Reference

1.Ningyan Wong, Peilin Cheryl Marise Tan, Zee Pin Ding, Khung Keong Yeo, Successful MitraClip for severe rheumatic mitral regurgitation: a case report, European Heart Journal – Case Reports, Volume 3, Issue 3, September 2019

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Why should mitral  annulus gets calcified ? .  Degenerative  calcification can be benign in  elderly .  If it occurs prematurely (say < 55 years )   there is enough reasons to worry .  This may represent a systemic vascular inflammation and  is considered a surrogate marker for athero- vascular -sclerosis .  A study from Cidar Sinai  , Los angels  has well documented the link way back in 2003  !

mitral annular calcification mac cad link

This is a  large study involving  17 735 patients (who were investigated for symptoms of CAD )   were screened.

The incidence  of MAC was high (As expected !)

  • 35% > 65 years
  • 5 %  < 65 years
Angiography  revealed more surprises .
  • The incidence of angiographic  CAD among those who had MAC and no MAC   was  88% v68% respectively ,( p = 0.0004),
  • Left main coronary artery disease  was (14% 4%, p = 0.009)
  • Triple vessel disease  was (54% v33%, p = 0.002).

mitral annular calcification  www_drsvenkatesan_co_in

Image source  S.Atar ,  Heart 2003 : 89, 161-164

Conclusion
This study concluded ,  CAD is more aggressive in patients with MAC. It can  also be  an independent  predictor of  high risk CAD .
Further Implications  of MAC
  1. MAC is more common in women, especially diabetics .
  2. Degenerative Mitral regurgitation  is common ,rarely  mitral stenosis
  3. Recurrent VPDs and even  trouble some mitral annular VT is possible
  4. Extensive calcific lesions in coronary  artery is also reported with MAC.
Link between Stroke and MAC .
This was well proven by this paper  published in  NEJM in 1992.
MITRAL ANNULAR CALCIFICATION AND STROKE NEJM  EMELIA BENJAMIN 1992

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Mitral valve prolapse  probably is the most common cause for  abnormal added  sounds in cardiac auscultation . MVPS occurs  when  mitral valve tissue  and its accessories  overgrow disproportionately    with reference to  the mitral valve orifice (Also referred to elongated or redundant leaflet) .The net mass  of mitral valve apparatus has an inverse relationship with  LV  cavity volume . Because of  excess motion  ,  leaflet may bulge into left atrium to different degrees and different angulations. This entity  as rule is  benign  in most people . Still ,  rampant diagnosis in the community  (With the  pathological proliferation of   scan centers  )  has raised considerable anxiety .

watch?v=esDNcqop_Ew&feature=relmfu

Hence , the criteria  to  diagnose MVPS are made stricter .Unless the leaflets are thickened and some degree of MR  occurs the  usage of the term MVPS  is  not justified .

watch?v=h6aJSuUTVb0

Unusual  sounds in MVPS

In many patients ,  AML become so nimble ,  it flexes, bends and   stretches  in both systole and diastole. These leaflets   can generate clicks  not only during  prolapse . Simple folding and unfolding of  long redundant  is known  to produce clicks.

generally folding occurs in diastole and unfolding in systole ( of course in extreme redundancy  both can occur in both phases )

This diastolic  clicks in MVPS has been reported rarely  in literature . It is   more common than we realise .The timing  of these clicks  are  not constant .Audibility is low .It can easily  be confused with opening snap of mitral stenosis .

The spatial  relationship between the sound generation and the anatomical prolapse  does not match . It is always  possible  when  PML prolapses  AML may generate a click and vise versa . Diastolic clicks or opening snaps  are known to occur in some of the severe forms of MVPS.  The first heart sound is not only loud  , the  differential  motion AML and PML  may distort  two componets of  M1  .It needs to be emphasized the loudness  of  S1  can be  preserved even in the presence of significant MR .(Even as the PML prolapses  causing MR ,  an  elongated  AML continues to generate a booming S 1)

Final message

Can MVPS produce diastolic added sounds ?   Yes . . . it can .

Mid systolic click  , and  late systolic murmur  is the classical  manifestation of MVPS . In reality , one can get a variety of noises from prolapsing mitral valve apparatus in both phases of cardiac cycle.

Reference 

These are all inferred from bed side observation . Luckily  I have found a  reference from a New york state journal of medicine .Other wise my observations would have been ridiculed .  Gone are the days   when we spend  hours together  in  clinical auscultation  of mitral valve motion  .

Today we are  in the era  , working in hi- tech cath labs ,  aiming  to  capture those same  redundant  mitral leaflets  with catheters  and clip its wings to reduce the mitral regurgitation  .

Asking for a phon0-cardiographic  documentation of diastolic mitral click in MVPS    would be a laughing stock among current generation cardiologists  !  Still I would argue for such a study !

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