"Clipping the Leak" - A Case Series of Transcatheter Mitral Valve Repair after Left Ventricular Assist Device

Introduction Mitral regurgitation (MR) often co-exists with severe left ventricular (LV) systolic dysfunction and there is controversy regarding the need for corrective surgery at the time of left ventricular assist device (LVAD) implantation as it often improves with mechanical LV unloading. We describe three patients with significant MR after LVAD implant in which transcatheter mitral valve repair (TMVR) [MitraClip] was utilized. To our knowledge, this is the largest case series of TMVR post-LVAD implant reported. Case Report Patient #1 is a 40-year-old male with severe LV dysfunction due to a non-ischemic cardiomyopathy (CM) who presented in cardiogenic shock (CS) and underwent centrifugal-flow LVAD [Heartmate 3]. MR was severe due to bileaflet tethering at time of implant and improved to mild to moderate immediately after. With medical and device optimization, EF improved to 35-40% however he had right ventricular (RV) dysfunction with recurrence of severe MR secondary to bileaflet prolapse. Given NYHA III symptoms, he underwent TMVR with improvement in MR to mild to moderate and improvement in his symptoms to NYHA class II. Patient #2 is a 27-year-old female who presented with acute severe LV dysfunction with moderate to severe functional MR due to viral myocarditis. She required extracorporeal membrane oxygenation and initially improved but decompensated after removal of support and subsequently underwent implantation of Heartmate 3. Her LV function recovered and she was scheduled for LVAD explantation but pre-operative tranesophageal echocardiogram revealed moderate to severe MR secondary to bileaflet prolapse so the procedure was deferred. She successfully underwent TMVR with improvement to mild to moderate MR and is planned for LVAD explant in the future. She had unchanged NYHA I symptoms before and after TMVR. Patient #3 is a 76-year-old male who underwent an axial-flow LVAD [Heartmate 2] seven years prior for ischemic CM. He reported worsening dyspnea despite device and medication optimization and was found to have moderate to severe MR (secondary to leaflet tethering). He underwent a successful TMVR with reduction in MR to mild to moderate, as well as improvement of NYHA class III to II. Summary Persistence of MR after LVAD implantation can be associated with worse outcomes. We describe three patients who underwent successful TMVR to reduce morbidity.