A 55 years old man that had in 1998 a mechanical aortic valve replacement, presents with dyspnea class III of NYHA related to a massive mitral regurgitation, type III, causing a dilation and severe left ventricular systolic dysfunction (FELV= 28-30%, End diastolic diameter=80mm).
Dear Dr. Madani:
Do you have additional data like a VO2max? Is he suitable for a MitraClip procedure? What is his pro-BNP?
From your information he sounds like a possible candidate for an interventional procedure.
In case of redo surgery you might have difficulties weaning him from CPB with such a ventricle and the long-term benefit of mitral valve surgery in such a patient can be worse than you expect.
Regards,
I. Aleksic
Dr Madani, that's becoming quite a common scenario!
Well, before evaluating surgical or interventional procedures I think the patient's background therapy should be reviewed and aggressively titrated if possible; a possible ischemic component should also be excluded (especially in case your pt had his last coronary angio in 1998...); resynchronization should be evaluated if his QRS is wide.
Your patient is certainly a poor candidate for surgery, due to both extreme LV remodeling and MR mechanism (I assume it is tethering from what you write), so every effort should be made to improve LV function non-inteventionally. Less is known about his possible response to MitraClip, but most experts (and a few published papers) agree that patients like yours are bad candidates for Clip as well...
Anyway, if no other option exists, I think you should consider a MitraClip procedure, possibly whilst starting routine evaluation for heart transplantation.
Dear Ivan Aleksic, and dear Guido Carlomagno,
thanks a lot for the answers you give me.
for my patient, medical therapy is optimal. a mitral procedure is recommended. But the problem is that, in Morocco, no center experience mitraclip. Surgery seems to be the only solution!!!
best regards.
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