Special Article - Mitraclip
Austin J Vasc Med. 2016; 3(1): 1016.
Cardoso C¹*, Garcia T¹, Cachado P¹, Cacela D², Branco L² and Monteiro A²
¹Department of Internal Medicine, Central Lisbon Centre, Portugal
²Department of Cardiology, Central Lisbon Centre, Portugal
*Corresponding author: Catarina Cardoso, Department of Internal Medicine, Santa Marta Hospital, Central Lisbon Centre, Portugal
Received: June 06, 2016; Accepted: July 10, 2016; Published: July 11, 2016
Congestive hepatopathy is a symptom of right-sided heart failure; significantly lowering quality of life and increasing hospital admissions.
Mitraclip has emerged as a treatment option in high surgical risk patients with severe mitral regurgitation and its associated symptoms such as dyspnea and fatigue. It is mainly indicated in degenerative valve disease, but functional regurgitation treatment is currently being evaluated in randomized trials.
We report a case of highly symptomatic congestive hepatopathy treated with severe mitral regurgitation reduction after Mitraclip implantation.
Keywords: Right heart failure; Congestive hepatopathy; Functional regurgitation; Mitraclip
Mitraclip is currently used in symptomatic heart failure patients with severe mitral valve regurgitation unable to undergo surgical treatment . Mitral valve regurgitation is an important cause of morbidity in heart failure due to its symptoms and patients perceive them differently . Although dyspnea and fatigue are the most commonly reported, right heart failure complaints such as those related to liver congestion are not negligible [3,4] and therefore are also important to consider if our aim is to improve patient’s overall well being.
Functional mitral regurgitation is common in dilated cardiomyopathy and up to 50% of symptomatic heart failure patients with severe regurgitation are not treated due to the high risk surgical procedure . The role of Mitraclip in this type of disorder has been evaluated on the following observational studies: EVEREST II, TRAMI, ACCESS-EU, MARS, European Sentinel, MitraSwiss, French multicentre registries, Treede et al., Bozdag-Turan et al., Rudolph et al., Braun et al., Neus et al., with improved clinical outcomes [6-17].
We report a case of a patient with ischemic dilated cardiomyopathy with biventricular dysfunction whose main symptoms were related to congestive hepatopathy unresponsive to pharmacological treatment. We were able to successfully manage this issue with Mitraclip implantation.
A 65-year-old man with a past medical history of hypertension, stage three chronic kidney disease, permanent atrial fibrillation and ischemic dilated cardiomyopathy with New York Heart Association (NYHA) class 2 heart failure was hospitalized due to one-month history of worsening of bilateral leg edema, abdominal right upper quadrant discomfort with nausea (especially after meals), subsequent weight loss (11 pounds) and anorexia. He also reported dyspnea on mild exertion with no fatigue, but according to the patient those were not considered important complaints with limitation in daily life activities. He denied other gastrointestinal symptoms, fever, night sweats, cough, palpitations, chest and low back pain or even genitourinary symptoms.
On general examination, he had a body mass index of 18 kg/ m² and at rest he did not have dyspnea. He was anicteric, wellhydrated and demonstrated right internal jugular vein distention. Cardiopulmonary auscultation revealed a grade 5 systolic murmur at the apical area with axillary irradiation and discrete bilateral lung rales. Abdominal examination elicited pain during superficial palpation on the right upper quadrant with hepatomegaly identification, with no signs of ascites. He had significant symmetrical peripheral pitting edema without any signs of deep vein thrombosis. His vital signs were normal, including fever absence. There were no additional examination abnormalities.
Abdominal ultrasound showed signs of congestive hepatomegaly with a dilated inferior vena cava (Figure 1) and a diffuse gallbladder wall thickening with small ascites, without additional complications. Laboratory studies only showed a mild cytocholestatic pattern (alkaline phosphatase 167 IU/L; aminotransferase 76 IU/L; alaninetransferase 80 IU/L; total bilirrubin 2.0 mg/dL). Chest x-ray did not show additional changes besides those previously known such as cardiomegaly. Electrocardiogram showed atrial fibrillation with a normal heart rate. Brain natriuretic peptide was 690 ng/L.
Figure 1: Dilated inferior vena cava.
It was considered a clinical case of right heart failure whose main complaints were related to liver congestion.
He was later transferred to a medical ward where he began diuretic treatment but after one week his symptoms did not show any improvement, worsening whenever he ate with early satiety, recurrent right upper quadrant discomfort and bloating. He was not able to increase his dietary intake in order to gain weight and became depressed with this condition.
He underwent additional investigation with doppler abdominal ultrasound, abdominal and pelvic computed tomography scan and endoscopic studies which found no abnormalities.
A transesophageal echocardiography documented left dilated ventricle dysfunction (telessystolic diameter- 65 mm/m²) with the same low ejection fraction (21%), but with severe mitral regurgitation (Figure 2). It showed posterior leaflet retraction with an eccentric jet swirling in left atrium; Effective Regurgitant Orifice Area (EROA) - 0.4 cm², regurgitant volume - 46 mL. Bilateral atrial dilation was present (right atrium 42 mL/m²), non-dilated right ventricle dysfunction;
Figure 2: Transesophageal echocardiography showing severe functional mitral regurgitation.
Tricuspid Annular Plane Systolic Excursion (TAPSE) - 11 mm; tricuspid annular systolic velocity - s’ 8 cm/sec with mild tricuspid regurgitation and moderate systolic pulmonary hypertension (50 mmHg).
His symptoms were attributed mainly to right heart failure due to left ventricle dysfunction with severe functional mitral regurgitation. He was considered a high-surgical risk patient and therefore this issue was discussed with interventional cardiology. Since the patient did not fulfill criteria for resynchronization therapy, he was considered for Mitraclip device after echocardiographic assessment to determine eligibility for this percutaneous approach.
Two Mitraclip were placed with demonstration of nonsignificant transmitral gradient of 1mmHg after the procedure. Mitral regurgitation improved from grade four to one (Figure 3) and it was documented a small interatrial communication. (10,4x22,6 mm).
Figure 3: Transthoracic echocardiography after mitraclip implantation showing mild mitral regurgitation.
He was discharged with no registered complications during his hospital stay.
After one month no abdominal symptoms were present, he regained appetite with weight and mood improvement and was in NYHA class II. Transthoracic echocardiographic evaluation after one month showed no worsening on parameters such as mitral regurgitation which remained in grade one (EROA - 0,19 cm², regurgitant volume - 29 mL). Additional measurements showed small improvements such as right atrial volume reduction (31 mL/m²), TAPSE increase (14 mm), systolic pulmonar hypertension reduction (45 mmHg) and a non dilated inferior vena cava (Figures 4 & 5). Left ventricular function did not change significantly (29%).
Figure 4: Non-dilated inferior vena cava.
Figure 5: Inferior vena cava diameter variation with inspiration.
This case highlights the importance of devices such as Mitraclip on less common and usually overlooked heart failure symptoms.
Congestive hepatopathy is frequently assymptomatic, but mild discomfort in the right upper abdominal quadrant with early satiety; nausea and anorexia are reported in some patients. Our patient experienced a significant burden when suffering from these symptoms, which usually improve with diuretic therapy. Untreated longstanding congestion can lead to cardiac fibrosis and ultimately cardiac cirrhosis . Adequate nutrition and mainteinance of a normal body mass index is important in heart failure, because weight loss is one of its consequences. Catabolic processes and neurohormonal and immune activation are some of the factors involved, but diminished food intake due to early satiety caused by congestive hepatomegaly is an additional important mechanism whose treatment is mainly pharmacological systemic venous decongestion .
Dilated cardiomiopathy is frequently complicated by functional mitral regurgitation and although surgical treatment has been advocated to correct it, most of the patients have high-surgical risk with significant mortality rates, which limit adequate candidates.
Mitraclip’s current role on functional mitral regurgitation treatment, as opposed to degenerative mitral valve disease, remains unclear. Despite the lack of official recommendations, ongoing trials about this matter such as COAPT, RESHAPE-HF may help clarify the problem and eventually strengthen or add labeling claims regarding benefits of Mitraclip in this condition.
Life quality is currently one major desire in chronic heart failure patients. This is the first clinical case report demonstrating the successful role of Mitraclip in gastrointestinal symptoms related to chronic right heart failure.
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Citation: Cardoso C, Garcia T, Cachado P, Cacela D, Branco L and Monteiro A. Mitraclip Benefits in Right-Sided Heart Failure: A Case Report. Austin J Vasc Med. 2016; 3(1): 1016.