Case Report: Intraoperative management of percutaneous mitral repair with the MitraClip system

Abstract

Percutaneous mitral repair using the MitraClip system decreased mitral regurgitation (MR) severity and improved NYHA functional class in patients with symptomatic severe MR. Hence, it became an alternative to conventional surgical repair for patients at high risk due to its comorbidities. The purpose of this report is to present the first case of percutaneous repair of MR with the MitraClip device in a patient with severe MR in the state of Rio Grande do Sul, Brazil, as well as the anesthetic implications involved. Female patient, 81 years old, ASA III due to symptomatic severe mitral MR (NYHA functional class III), anemia, atrial fibrillation and anxiety disorder. The patient underwent venous general anesthesia induction and balanced maintenance, monitored with invasive arterial pressure, cardioscope, pulse oximetry, capnography, temperature probe and transesophageal echocardiography (TEE). Throughout the procedure, after multiple transseptal punctures, cardiac tamponade was diagnosed. Subsequent hemodynamic instability was controlled with pericardial drainage, autotransfusion and heterologous transfusion as well as by use of vasoactive drugs. MitraClip placement guided by TEE performed successfully on the first attempt. Immediate reduction of MR (from baseline grade 3 to 1 immediate post procedural), without additional clipping. Postoperative care provided in cardiac intensive care unit. Bleeding in the femoral vein puncture site, previously closed with Perclose Proglide® device, was presented in the immediate postoperative period. After intensive care management, patient progressed to clinical stability and was discharged from hospital on the fourth postoperative day. Since this was the first MitraClip implantation held at the institution, it was decided to be performed under general anesthesia and invasive monitoring. This has truly improved diagnostic and anesthetic management. The reported perioperative complications were diagnosed and managed promptly owing to the intensive care provided and TEE played a critical role in it. Knowledge of the steps involved, in order to anticipate possible complications, and multidisciplinary teamwork were paramount to the procedure success, which is a feasible alternative in high risk patients with symptomatic severe MR.