The Limits and Beyond: Challenges in Mitral Ring Dehiscence
Image Modality: Illustration Table Figure
A 75-year-old male patient with a medical history of coronary artery disease and coronary artery bypass grafting with an ischemic cardiomyopathy status post-biventricular implantable cardioverter-defibrillator placement and persistent atrial fibrillation who previously underwent a surgical mitral valve repair with a 34-mm annuloplasty ring in 2012 presented in acute heart failure. A transthoracic echocardiogram showed severe mitral regurgitation (MR).
A transesophageal echocardiogram demonstrated multiple areas of mitral annular ring dehiscence, the largest of which was posteromedial. Etiology of the MR was felt to be from both restriction and tethering of the posterior mitral leaflet as well as annular dilation.
The patient was deemed a high surgical risk, and his case was presented to the structural heart multidisciplinary team. Annuloplasty ring dehiscence rate is variable and usually results in recurrent MR. Recurrent MR is usually secondary to annular dilation at the area of dehiscence with subsequent leaflet malcoaptation and results in high risk for surgical revision.
The multidisciplinary team considered transcatheter mitral valve replacement. Early experience with transcatheter mitral valve replacement has shown feasibility with acceptable outcomes.1 However, this was felt to be a poor option due to technical considerations from a rigid ring, possible commissural leak due to sizing considerations, and outflow tract obstruction risk at the neo-left ventricular outflow tract.
An alternative approach that was considered was the performance of transcatheter edge-to-edge repair of the mitral valve with a MitraClip (Abbott; Abbott Park, IL). Success of this approach has been reported in the literature.2 However, careful review of the transesophageal echocardiogram suggested poor leaflet anatomy for a successful procedure.
Ultimately, it was felt that a transcatheter approach was not feasible at this time. Transcatheter interventions on the mitral valve involve complex decision-making, particularly in the setting of a dehisced mitral ring. Despite rapid advancements in this area, significant limitations of current techniques exist and require future development.
- Yoon SH, Whisenant BK, Bleiziffer S, et al. Outcomes of Transcatheter Mitral Valve Replacement for Degenerated Bioprostheses, Failed Annuloplasty Rings, and Mitral Annular Calcification. Eur Heart J 2019;40:441-51.
- Hanson ID, Hanzel GS, Shannon FL. Mitral Valve Repair After Annuloplasty Ring Dehiscence Using MitraClip. Catheter Cardiovasc Interv 2016;88:301-6.
Date: May 29, 2020
Authors: Victor Farah, MD, FACC
Keywords: Diagnostic Imaging, Cardiac Imaging Techniques, Mitral Valve, Surgical Wound Dehiscence, Heart Valve Diseases