History
This 76-year-old female patient was referred to us for persistent heart failure symptoms in New York Heart Association [NYHA] class III to IV and severe functional mitral regurgitation (FMR) despite optimal therapeutic management combining medication, previous biventricular implantable cardioverter-defibrillator (ICD) (cardiac resynchronization therapy defibrillator [CRT-D]) implant, and atrioventricular node ablation for competing atrial fibrillation rhythm. Four months previously a CRT-D device was implanted based on conventional class I indication—drug-refractory symptomatic heart failure (NYHA class III to IV) because of postactinic cardiomyopathy (the patient had previously received radiotherapy for non-Hodgkin lymphoma) with severe left ventricular systolic dysfunction (left ventricular ejection fraction [LVEF], 29%); the electrocardiogram (ECG) showed significant ventricular conduction delay with complete left bundle branch block and 130-msec QRS complex duration. Atrial fibrillation was the underlying atrial rhythm. Besides severe left ventricular dysfunction, the transthoracic echocardiogram performed before CRT-D device implant showed a mildly dilated left ventricle (end-diastolic voume 186 mL and end-systolic volume 132 mL) and severe functional mitral regurgitation determined by failed coaptation of mitral valve leaflets resulting from symmetric dilation of the mitral anulus. Shortly after CRT-D implant, the patient underwent catheter ablation of the atrioventricular node as a result of recurring high ventricular rate atrial fibrillation.
After 4 months of CRT, both symptoms and mitral regurgitation remained unchanged. The patient was therefore evaluated for percutaneous edge-to-edge mitral valvuloplasty with a MitraClip (Abbott Laboratories, Abbott Park, Ill).1
Current Medications
The patient was taking acenocoumerol 1 mg adjusted to international normalized ratio value, captopril 10 mg daily, carvedilol 12.5 mg daily, spironolactone 50 mg daily, torsemide 20 mg adjusted according to weight, and metolazone 2.5 mg daily if body weight greater than 50 kg.
Comments
The medication profile of the patient is typical for advanced-phase heart failure, with low dosages of an angiotensin-converting enzyme inhibitor and beta blockers and weight-adjusted dosages of diuretics.
Current Symptoms
The patient was unable to walk up a single flight of 12 steps without stopping because of breathlessness (NYHA class III to IV) and unable to perform the 6-Minute Walk Test.
Physical Examination
Laboratory Data
Comments
Life expectancy considering the patient’s demographic, clinical, and laboratory data was calculated using the Seattle Heart Failure Model.2 Estimated life expectancy for this patient was considered to be very poor, with a median life expectancy of 2.6 years and estimated survival of only 69%, 48%, and 16% at 1, 2, and 5 years, respectively.
Electrocardiogram
Findings
Constant biventricular paced rhythm was seen in VVI modality at 70 bpm (Figure 44-1). The vertical axis in the peripheral leads demonstrated a QRS duration of 120 msec. The underlying atrial rhythm was atrial fibrillation.
Echocardiogram
Findings
Figure 44-2 shows the transthoracic echocardiographic apical four-chamber view with color Doppler before (see Figure 44-2, A) MitraClip positioning.
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