Transthoracic echocardiography on the seventh post-operative day showed the dislodged mitral annuloplasty ring.
An 89-year-old man underwent mitral valve annuloplasty (MAP) with a 28 mm Cosgrove annuloplasty ring for moderate AFMR associated with long-standing atrial fibrillation and enlarged atria and tricuspid valve annuloplasty (TAP) for severe tricuspid regurgitation (TR) with a 32 mm MC annuloplasty ring in November 2015. Post-operative transthoracic echocardiography (TTE) on Day 7 indicated a dislodged mitral annuloplasty ring and moderate AFMR recurrence, with controlled TR. Thus, a watchful waiting strategy was adopted, and 7 years passed without recurrence of heart failure (HF). However, in 2022, the patient was hospitalized twice for HF with the New York Heart Association (NYHA) Class III symptoms under the following medications for HF: azosemide (30 mg), torasemide (4 mg), tolvaptan (15 mg), bisoprolol (0.625 mg), valsartan (40 mg), and empagliflozin (10 mg). On admission for congestive HF, physical examination suggested an oxygen saturation of 94% on room air and bilateral pretibial oedema. Auscultation suggested coarse crackles in the lung fields and a pan-systolic murmur of Levine grade II at the apex. His blood pressure was 115/57 mmHg, pulse rate was 84 b.p.m., and a 12-lead electrocardiogram indicated right ventricular pacing of 84 b.p.m. The chest X-ray suggested cardiac dilation (cardiothoracic ratio = 65%), pulmonary congestion in the lung fields, and bilateral pleural effusion. Blood exam indicated an elevated N-terminal pro-B-type natriuretic peptide level of 2476 pg/mL. On TTE, the left ventricular (LV) end-diastolic diameter had increased to 54 mm, with a preserved LV ejection fraction of 62% (end-diastolic/end-systolic volume = 143/54 mL). A detached ring was observed in the left atrium at the mitral annulus level ( Figure 1 ). The left atrial volume index suggested substantial enlargement at 139 mL/m 2 . Transthoracic echocardiography demonstrated worsened AFMR with an effective regurgitant orifice area of 0.35 cm 2 and a regurgitant volume of 55.4 mL ( Movie Clip A ). The TR was controlled to be mild. Transoesophageal echocardiography (TOE) indicated a ‘flat valve’ with a shallow coaptation of the mitral valve (MV) with partial pseudo prolapse. Moreover, the MV coaptation was located immediately below the dislodged prosthetic annulus ring; the MR jet collided with the displaced posterior ring ( Figure 2 , Movie Clip B ). Three-dimensional TOE analysis indicated an MV area of 3.9 cm 2 . He was deemed to be at a relatively high surgical risk, with STS scores of 7.3% and 12.9% for valve repair and replacement, respectively. Therefore, TEER was selected as the final treatment strategy for the cardiology team discussions. The following issues were deliberated because the MV coaptation almost touched the detached ring during systole: (1) route of entry of the clip delivery system (CDS), whether it should enter from the anterior space inside the ring or posterior peri-ring space; (2) a distance of ∼5 mm between the shaft and ring required to lower the gripper down without interfering with the ring; and (3) whether the clip arm could be closed without touching the ring. From the TOE analysis, we decided to approach the flat MV vertically by pushing the CDS through the peri-ring space with the shaft away from the aorta ‘reverse aorta hugger’. Therefore, the septal puncture was planned to be performed as posteriorly as possible. Moreover, a distance of ∼5 mm between the shaft and ring could be ensured on the medial side of A2–P2 to lower the gripper down ( Figure 3 ). In addition, the length of the P2 segment, which was the target for TEER, was 10.7 mm, and the mean trans-mitral gradient was elevated at 4.0 mmHg. For these reasons, it was determined that the only device option capable for TEER in this case was NT clip. Successful MV grasping was achieved by the planned entry of the NT ( Figure 4 ), as indicated by the intra-procedural TOE. Subsequent positioning optimization by steering down in the antero-inferior direction closed the clip arm, resulting in a substantial reduction in MR ( Figure 5 and Movie Clip C ). The patient’s post-operative course was uneventful, and the NYHA functional class at 9 months was II. Transthoracic echocardiography suggested a stable clip and mild residual MR. To date, the patient has not been admitted for HF-related hospitalization during the subsequent 1.5 years.
Parasternal long axis view in end-diastole ( A ) and end-systole ( B ) and apical long axis view in end-diastole ( C ) and end-systole ( D ) with the detached annuloplasty ring (arrow) on transthoracic echocardiography.
Multiplane view presenting the commissural view (left: 20°) and left ventricular out tract view (right: 110°) in transoesophageal echocardiography (TOE) ( A : end-diastole, B : end-systole, and arrows: detached annuloplasty ring). Detached annuloplasty ring and atrial functional mitral regurgitation ( C and D ) and its three-dimensional TOE image ( E and F ).
Positional relationship of the clip presumed to be the detached annuloplasty ring and the anticipated direction of clip insertion (dashed arrow); on the A2–P2 medial side, there is a possible 5 mm space between the dislodged ring and the shaft.
Clip inserted into the left ventricle in the intraoperative transoesophageal echocardiography (TOE) and success of the anterior gripper (arrow) down without interfering with the ring ( A ). Fusion of the real TOE image and schematic ( B ).
Intraoperative transoesophageal echocardiography (TOE) images before (left) and after transcatheter edge-to-edge repair (right) with improved mitral regurgitation.
This case involved a patient who underwent MAP and TAP for severe TR combined with moderate AFMR 7 years ago. Annuloplasty ring dehiscence was confirmed 1 week after surgery; nonetheless, the patient was managed conservatively for several years. After 7 years, TEER was performed successfully for congestive HF caused by AFMR. The uniqueness of this report lies in AFMR recurrence, with the detached ring positioned adjacent to the MV coaptation and meticulous planning performed before the procedure.
A report from a high-volume single institution between 1996 and 2016 of 3478 patients who underwent valvuloplasty and annuloplasty for degenerative MR showed that 57 (1.6%) patients experienced ARD, of which 44% occurred within 1 month and largely in the posterior regions. The 30-day mortality after reoperation for MV was 2%, with 1- and 5-year survival rates of 89% and 74%, respectively. During reoperation, MV replacement was performed in 38 cases (67%), whereas MV re-repair was performed in 19 cases (33%). 2 Transcatheter edge-to-edge repair has been widely recognized as an effective, safe, and proven catheter-based treatment for MR in patients at high surgical risk; it has established efficacy and long-term outcomes. 3–5 However, only few reports have elucidated TEER for recurrent MR with ARD. 6–9 According to a report from a single centre, of 795 patients with TEER, six patients with ARD underwent treatment using the MitraClip system (Abbott, Santa Clara, CA, USA), and all six achieved technical success. 7 Leurent et al. demonstrated that technical success rate of the TEER was 100% in 23 patients with recurrent MR after surgical mitral annuloplasty from the multicentre ‘Clip-in-Ring’ registry. At discharge, residual MR grade was ≤2+ in 87% and median trans-mitral gradient was 4 [3–5] mmHg. 10 Therefore, TEER can be recognized as a technically feasible option for treating MR recurrence caused by ARD. Patients with recurrent MR from ARD have poor prognosis; however, TEER can be performed with ingenuity to improve the symptoms and avoid readmission for HF. In addition, transcatheter mitral valve implantation (TMVI) may become one of the treatment options for recurrent MR after mitral valve surgery. 11 In fact, a case of TMVI performed for recurrent MR with ARD was reported. 12 Our report highlights a relatively rare case of TEER in which the CDS was approached from the posterior of the peri-ring and perpendicular to the MV ‘reverse aorta hugger approach’. This is because posterior of the detached ring was located anteriorly distant from the norm. Depending on the degree of ring dislodgement, it may be preferable to deliver the CDS with an ‘aorta hugger’ through the ring. 7 Therefore, pre-operative anatomical evaluation is necessary.
Furthermore, AFMR with a giant left atrium was the primary aetiology of MR in this case. The gripper and the opening and closing of the clip arm could interfere with the ring because the MV coaptation was adjacent to the ring. Therefore, it was necessary to simulate the insertion position and gripper down within a few millimetres. The strength of this paper lies in the detailed pre-operative meticulous planning conducted under TOE guidance.
Recurrent AFMR with ARD is rare; however, TEER is a feasible procedure with a well-developed pre-procedural strategy using TOE.
Dr Ryota Kosaki graduated from Aichi Medical University in 2012 and completed doctoral programme at Showa Graduate School of Medicine. He works at Showa University Hospital and specializes in catheter intervention for ischaemic heart disease and structural heart disease.
Supplementary material is available at European Heart Journal – Case Reports online.
We would like to thank Editage ( www.editage.com ) for English language editing.
Consent : The authors confirm that written consent for the submission and publication of this case report, including images and associated text, was obtained from the patient in line with COPE guidelines.
Funding: None.
The data underlying this article will be shared upon reasonable request with the corresponding authors.
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Kodama K , Horibata Y , Konami Y , Horio E , Yamada M , Taguchi E , et al. Successful transcatheter edge-to-edge repair using the mitraclip G4 system for a patient with severe mitral regurgitation due to surgical annuloplasty ring detachment . Circ J 2021 ; 85 : 2116 .
Otero D , Raza M , Kahlon T , Singh V . Transcatheter edge-to-edge mitral valve repair for annuloplasty ring dehiscence: the peri-ring approach . Catheter Cardiovasc Interv 2021 ; 97 : E727 – E730 .
Leurent G , Auffret V , Grinberg D , Le Ruz R , Saint Etienne C , Pierrard R , et al. Transcatheter edge-to-edge repair following surgical valve repair with ring implantation: results from the multicentre “Clip-in-Ring” registry . Arch Cardiovasc Dis 2022 ; 115 : 521 – 528 .
Russo G , Gennari M , Gavazzoni M , Pedicino D , Pozzoli A , Taramasso M , et al. Transcatheter mitral valve implantation: current status and future perspectives . Circ Cardiovasc Interv 2021 ; 14 : e010628 .
Maisano F , Reser D , Pavicevic J , Nietlispach F , Gämperli O , Schmid M , et al. Successful first-in-man Melody transcatheter valve implant in a dehisced mitral annuloplasty ring transapical valve-in-ring implant . EuroIntervention 2014 ; 10 : 961 – 967 .
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Obama praised President Biden and offered support for Harris.
Vice President Kamala Harris officially became the official Democratic presidential nominee during the second night of the Democratic National Convention.
The night included a lively and upbeat roll call vote of delegates that featured a DJ, some celebrities and energetic speeches. Also, Harris, who campaigned in Milwaukee, thanked the crowd in a live-streamed message.
Second gentleman Doug Emoff talked about his long relationship with Harris and touted her vision for the country.
But the night's biggest headline was the return of former President Barack Obama and first lady Michelle Obama to the DNC stage. Both stressed what's at stake in this election and pushed Americans to come together to bring the country to a better future.
Harris posted a photo of her watching the second gentleman's speech at the DNC Tuesday night.
"Love you, Dougie," she wrote on the social media post .
After more than 30 minutes on stage, Obama had a simple message for convention-goers.
"As much as any policy or program, I believe that’s what we yearn for, a return to an America where we work together and look out for each other," Obama said.
"That is what this election is about," he added. "And I believe that’s why, if we each do our part over the next 77 days, if we knock on doors, if we make phone calls, if we talk to our friends, if we listen to our neighbors, if we work like we’ve never worked before, if we hold firm to our convictions, we will elect Kamala Harris as the next president of the United States and Tim Walz as the next vice president of the United States."
"So let’s get to work. God bless you, and God Bless the United States of America."
Turning personal, Obama spoke about the bond he had with Michelle Obama's mother, who passed away earlier this year.
"One of the reasons Marian and I became so close was she reminded me of my grandmother, the woman who helped raise me as a child," he said.
"They were strong, smart, resourceful women, full of common sense who, regardless of the barriers they encountered ... In that sense, they both represented an entire generation of working people who, through war and depression, discrimination and limited opportunity, helped build this country," he said.
Obama said to build a true Democratic majority, they have to give grace to people who may not align with their political views.
"That sense of mutual respect has to be part of our message," he said. "Our politics have become so polarized these days that all of us across the political spectrum seem so quick to assume the worst in others unless they agree with us on every single issue."
"We start thinking that the only way to win is to scold and shame and out-yell the other side. And after a while, regular folks just tune out or they don’t bother to vote," he continued. "Now that approach may work for the politicians who just want attention and thrive on division, but it won’t work for us to make progress on the things we care about, the things that really affect people’s lives."
Obama later acknowledged those ideas "can feel pretty naive right now" but was adamant "the ties that bind us are still there."
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Here's a genericized executive summary slide based on material provided by a recent client. This recap was created to give the VP of Sales a comprehensive overview of last quarter's sales performance across all three company brands (A, B, and C). The full presentation deck contained about 30 slides, with detailed sections for each brand.
Here are a few tips for business professionals who want to move from being good speakers to great ones: be concise (the fewer words, the better); never use bullet points (photos and images paired ...
5 quick tips on how to write a summary for a presentation. Using A Non-Linear Writing Tool Like Milanote. Using A Presentation Template. Avoiding Wordy Slides. Keeping Eye Contact With The Audience. Using A Progress Bar To Indicate Where You Are In Your Presentation.
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Introduction Different people have varying needs for summaries. For a student, summaries are a great way to keep notes. They help them during their exam preparations. In businesses, summaries are often required during executive meetings. Any kind of report, plan, or strategy could require an executive summary. This is also where summarizing presentations is required. In businesses ...
Follow these steps when creating an outline for your presentation: 1. Consider the purpose of your presentation. When creating a presentation outline, determine your goal. To find this, think about what you want your audience to obtain or support after your discussion. For example, a nonprofit that builds wells for impoverished communities may ...
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In her speech at the Democratic National Convention in Chicago, former Secretary of State Hillary Clinton received a standing ovation, praised Vice President Kamala Harris and slammed former ...
Summary figure. Open in new tab ... Case presentation. An 89-year-old man underwent mitral valve annuloplasty (MAP) with a 28 mm Cosgrove annuloplasty ring for moderate AFMR associated with long-standing atrial fibrillation and enlarged atria and tricuspid valve annuloplasty (TAP) for severe tricuspid regurgitation (TR) with a 32 mm MC ...
For many watching at home, Gus Walz's emotional reaction to his father, Minnesota Gov. Tim Walz (D), as he spoke at the DNC was the highlight of the speech.
Harris will hold a 9 p.m. ET rally in Milwaukee. After more than 30 minutes on stage, Obama had a simple message for convention-goers.