Recently, Professor Wang Jue of the First Affiliated Hospital of Wenzhou Medical University, with the full cooperation of multiple departments including the Ultrasound Department, Anesthesiology Department, and Operating Room, successfully completed Wenzhou's first transapical mitral valve repair (TA-TEER) surgery on an elderly, high-risk patient with severe mitral regurgitation using the mitral valve clip system (ValveClamp^®). This surgery, which performs mitral valve clipping while the heart is beating, improves the patient's heart's blood supply and features "low surgical trauma" and "efficient and immediate cure." This surgery was also a highly challenging DMR case that Professor Wang Jue of the First Affiliated Hospital of Wenzhou Medical University independently completed using the ValveClamp^® transapical mitral valve clip system.

Background

Mitral regurgitation is a common heart valve disease worldwide, with an overall prevalence of 1.7%. The incidence increases with age. If left untreated, patients are at risk of arrhythmia, heart failure, stroke, and even sudden death. Interventional treatment for severe mitral regurgitation has always been a challenging and hot topic in the field of cardiovascular intervention. TEER has become an effective treatment for severe mitral regurgitation and is currently the most established and only transcatheter mitral valve intervention recommended by international and domestic guidelines. The transapical TEER procedure is simple to perform and offers highly effective clipping. It requires no thoracotomy, cardiopulmonary bypass, or X-rays. It is performed under pure transesophageal ultrasound guidance, resulting in minimal patient trauma and a rapid recovery.

Preoperative Discussion

Preoperatively, Professor Wang Jue, Director of Cardiac Surgery, led a case discussion of the patient's condition. A comprehensive analysis of surgical indications, potential intraoperative complications, and management strategies was conducted. After thorough evaluation, the team decided to perform transapical mitral valve clipping (TA-TEER) on this high-risk patient with severe mitral regurgitation.

Case Summary

Patient: 77-year-old female

Chief Complaint: 20-day history of mitral valve prolapse on physical examination, 20-year history of hypertension

Preoperative Diagnosis: Mitral valve prolapse (P2 and C1 prolapse into the left atrium) with severe regurgitation, left ventricular ejection fraction of 60%, aortic valve calcification, mild pulmonary hypertension, mild tricuspid regurgitation, patent foramen ovale; renal cysts, hepatic cysts, and post-cholecystectomy.

Preoperative Examination

The patient had primary mitral regurgitation (DMR). A mitral regurgitation signal was visible during systole, located in zones 2 to 3. The baseline mitral regurgitation severity was 4+.

Anterior leaflet length 15.7mm, posterior leaflet length 12.7mm, posterior leaflet prolapse width 13.9mm, prolapse height 4.76mm, annulus diameter 37.1mm, VC: 4*7mm, MVA approximately 4cm². The leaflet texture was poor, with chordae tendineae rupture and posterior leaflet prolapse.

Surgical Strategy

Due to the wide range of prolapse, to effectively reduce the degree of regurgitation, clipping is first performed perpendicular to the mitral valve closure line at the 2-3 position. If residual regurgitation persists after clipping, a second mitral clip is placed at the 2-3 position. Attention should be paid to the pressure gradient and valve orifice area.

Surgical Difficulties

The patient was elderly, with a 13.9mm wide posterior mitral valve leaflet prolapse, and comorbidities such as hypertension, aortic calcification, pulmonary hypertension, renal cysts, and liver cysts.

Preoperative ultrasound

Intraoperative Procedure

After general anesthesia, the mitral valve clip system was inserted through a small 3-4 cm incision between the ribs in the precordial area, exposing the apex of the heart. The system was then advanced into the left atrium, successfully reaching the area of ​​the diseased mitral valve. Assisted by transesophageal ultrasound, the surgeon repeatedly assessed the location of mitral regurgitation, the location of the apex, and the degree of regurgitation. Initially, a deft clip was performed perpendicular to the mitral valve closure line at zone 2-3. A ValveClamp MVC-IIf clip was implanted in zone 2 near zone 3. Final evaluation showed that the regurgitation was reduced to mild and the average transvalvular pressure gradient was reduced to 2 mmHg. The operation was a complete success.

Intraoperative Ultrasound (Key Step)

Postoperative Ultrasound