Robotic Assisted Mitral Valve Repair After Failed Transcatheter Edge-to-Edge Repair

The patient is a thirty-eight-year-old man with a familial history of dilated cardiomyopathy who initially presented to the hospital with shortness of breath. Workup revealed new onset atrial fibrillation, severe mitral regurgitation with P2 prolapse, and cardiogenic shock (LVEF 24 percent). He required inotropic support and placement of an intra-aortic balloon pump. Given his acute decompensated heart failure, the patient was deemed not a surgical candidate and underwent salvage transcatheter edge-to-edge repair of the mitral valve. Three clips were placed to obtain a satisfactory result. 

At his one month follow-up, the patient’s LVEF had improved to 64 percent. However, he was found to have worsening severe mitral regurgitation with the clips intact and dilation of the left ventricle. After a thorough discussion of valve repair versus replacement, it was chosen to make every attempt to repair the valve to address the initial pathology of valvular prolapse. This was accomplished with a robotic-assisted right mini thoracotomy approach. 

Upon opening the left atrium, redundant valvular tissue was apparent with three well-incorporated clips. These were removed by slow, careful, and meticulous dissection of leaflet tissue away from the grippers of the clip. The valve was then repaired with a P2 triangular resection and placement of a partial 42 mm annuloplasty band. This yielded a satisfactory repair with only trace mitral regurgitation on transesophageal echo after coming off bypass. 

Postoperatively, the patient did well and was discharged home on postoperative day five. At his one month follow-up visit, he reported return to baseline activity with no episodes of palpitations.

References

1. Rader F, Siegel RJ, Flint N, Minhas H, Shmueli YG, Shiota T, Trento A. Mitral Valve Surgery After Failed MitraClip: A Single-Center Experience. J Invasive Cardiol. 2021 Apr;33(4):E236-E243. PMID: 33794477.

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