Background
Patient: Male, 62 years old; recurrent chest tightness and shortness of breath for 9 months, worsened in the past week; history of atrial septal defect (ASD) repair with functional mitral regurgitation (FMR), lesion located at the mitral valve zone 2 towards zone 3. The patient's previous ASD repair increased the difficulty of atrial septal puncture.
Diagnosis and Examination
- Heart failure, New York Heart Association (NYHA) class III
- Coronary artery disease
- Hypertension
- Type 2 diabetes mellitus
- Valvular heart disease with severe mitral regurgitation and moderate tricuspid regurgitation
- Congenital heart disease, post-ASD occlusion
Surgical Procedure
Under the dual guidance of transesophageal echocardiography (TEE) and digital subtraction angiography (DSA), a puncture was performed at a lower and posterior position to avoid the ASD occluder. A single XTR device was used for mitral valve repair. The puncture site was 3.1 cm from the mitral annular plane, which was insufficient in height. The "A" knob was rotated 180 degrees to gain additional height. The LVOT view showed significant "Huge" deformation of the clip, which was corrected using the "+" knob to eliminate the "Huge" effect. The "M" knob was then manipulated to precisely position the mitral clip directly above zone 2, successfully capturing and securing the leaflets. TEE examination confirmed that mitral regurgitation was reduced to trace levels, and pulmonary venous flow reversal was significantly improved.
Conclusion
The presence of a previously implanted ASD occluder in the conventional puncture pathway greatly limited the feasibility of mitral valve intervention. In this case, a precise puncture strategy successfully established a surgical pathway, providing a viable solution for patients who have undergone ASD occlusion.
