Treatment of severe mitral regurgitation that mimics a para-ring mitral regurgitation after failed annuloplasty ring with MitraClip: A case report

BACKGROUND: Progressive remodelling of the left ventricle with lateral and apical displacement of one or both papillary muscles can lead to recurrence of severe mitral regurgitation (MR) in the presence of the mitral valve (MV) ring. The MitraClip (Abbott, USA) is the only option in cases with annuloplasty rings too large for implantation of a Sapien prosthesis in high surgical-risk patients. We present a case where the MR jet was directed toward a para-ring hole, and the MitraClip system was used successfully to treat this severe MR. CASE SUMMARY: An 80-year-old woman underwent coronary artery bypass surgery plus MV repair with C-shaped ring 6 years ago. In the past year, she experienced severe shortness of breath; her ejection fraction dropped to 15%. A transesophageal echocardiogram revealed that severe MR started at the level of MV leaflets and then passed to the left atrium beside the MV ring. Live 3D showed the severe MR coming through the oval-shaped hole beside the C-shaped MV repair ring. MitraClip implantation was decided, the two leaflets were grasped successfully, the clip was fully closed, and only trace MR remained at the MV leaflets with no flow to the para-ring hole. The patient was extubated after 12 hours and discharged home after 2 days. Follow-up transthoracic echocardiography after 6 months showed the clip in place and trace residual MR. CONCLUSION: Implantation of MitraClip in the presence of MV repair ring is feasible and safe. The para-ring defect can be left if the origin of MR from the MV coaptation line is treated successfully with MitraClip. Symptomatic improvement with no rehospitalization was documented in this case.