Computed Tomography Analysis Before Transcatheter Edge-to-Edge Repair for Mitral Regurgitation With Calcified Mitral Valve Apparatus

A 79-year-old woman underwent transcatheter edge-to-edge repair (TEER) using the MitraClip (Abbott Vascular, CA, USA) for symptomatic severe atrial functional mitral regurgitation (MR) because of her high surgical risk (14.4% for death according to Society of Thoracic Surgeons score). Transesophageal echocardiography (TEE) showed severe MR from the medial and lateral A2/P2 (Figure A) with mitral annular calcification (MAC) (Figure B). In the medial A2/P2, leaflet length was short (6 mm) with the MAC protruding into the left ventricle (Figure C). In the lateral A2/P2, the posterior leaflet appeared to be thickened and calcified, extending from the MAC (Figure D). Because leaflet calcification in the grasping zone is one of the unsuitable anatomies for TEER, the mitral valve apparatus was assessed by cardiac computed tomography (CCT), which showed severe MAC (Figure E) and the restricted medial P2 leaflet (6.5 mm; Figure F). Because the lateral P2 leaflet was not calcified and had sufficient length (8.3 mm; Figure G), NT clip implantation for the lateral A2/P2 was planned. After closing the clip with sufficient leaflet insertion (Supplementary Movie), MR was reduced to mild without apparent mitral stenosis (Figure H).

Figure.

(A) Severe mitral regurgitation (MR) from the medial and lateral A2/P2. (B) 3D image of mitral annular calcification (MAC; red arrows). (C) Restricted medial P2 leaflet attached to the MAC. (D) Thickened and highly echogenic lateral P2 leaflet. (E) Computed tomography images showing severe MAC. (F) Restricted medial P2 leaflet attached to the MAC, but the lateral P2 leaflet has sufficient length and no calcification (G). (H) MR reduced from severe to mild.

Although CCT needs contrast agent, it is more useful for evaluating mitral calcification than TEE because of its higher spatial resolution.¹ Detailed evaluation of a calcified mitral valve apparatus using CCT is recommended to determine the TEER strategy when leaflet calcification is suspected from TEE.

Conflicts of Interest

S.K. and T.M. are clinical proctors at Abbott Vascular.

Supplementary Files

Supplementary Movie. Grasping view.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-23-0714

Reference

• 1.   Kaewkes D, Kagawa S, Patel V, Omori T, Koseki K, Koren O, et al. Multidetector computed tomography in patients who underwent transcatheter mitral edge-to-edge repair. Am J Cardiol 2023; 208: 101–110.