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 concomitant functional mitral regurgitation (FMR), lesion located at the junction of zones 2 and 3 of the mitral valve. The prior ASD repair has increased the difficulty of transseptal puncture.
Diagnosis and Examinations
Heart failure, Class III heart function, coronary artery disease, hypertension, type 2 diabetes, valvular heart disease with severe mitral regurgitation and moderate tricuspid regurgitation, congenital heart disease post-ASD closure.
Surgical Procedure
Under dual guidance by transesophageal echocardiography (TEE) and digital subtraction angiography (DSA), a puncture was performed at a lower and posterior position to avoid the ASD closure device. A single XTR device was used for mitral valve repair. The puncture site was 3.1 cm from the mitral annular plane, but the puncture height was insufficient. The height was adjusted by rotating the "A" knob 180 degrees. The clip was severely Huge on the left ventricular outflow tract (LVOT) view, and the Huge was eliminated using the "+" button. By manipulating the "M" knob, the mitral valve clip was precisely positioned directly above zone 2, successfully capturing and holding the leaflets. TEE examination showed that mitral regurgitation was significantly reduced to trace levels, and pulmonary venous flow reversal was markedly improved.
Conclusion
The presence of a previous ASD closure device occupying the conventional puncture pathway greatly restricts 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 closure.
