Transapical transcatheter aortic valve implantation followed by transfemoral transcatheter edge-to-edge repair of the tricuspid valve using the MitraClip system – a new treatment concept for an inoperable patient with significant aortic stenosis and severe tricuspid valve regurgitation

Transcatheter mitral valve edge-to-edge repair using the MitraClip system (Abbott Vascular, USA) and transcatheter aortic valve implantation (TAVI) are well established in high-risk or inoperable patients with severe mitral regurgitation and severe aortic stenosis. The benefits of both methods have been confirmed in large cohort studies [1–4]. Recently, successful transcatheter tricuspid valve edge-to-edge repair using the MitraClip system was described for high surgical risk or inoperable patients [5–7].
Here we present to our knowledge the first case of transapical TAVI (TA-TAVI) followed by transfemoral clipping of the tricuspid valve using the MitraClip system.
An 81-year-old male patient with a history of biventricular heart decompensation suffered from severe dyspnea on admission (New York Heart Association functional class III), lower leg edema, ascites, pleural effusions and stage III chronic kidney disease. Echocardiography showed significant low-flow/low-gradient aortic stenosis (mean gradient 20 mm Hg, aortic valve area 0.9 cm²). In addition, severe tricuspid valve regurgitation (TR) with tethered leaflets was found (vena contracta area 1.22 cm² – 3D Echo, vena contracta width 10 mm). The mitral valve showed only mild regurgitation. Left and right ventricular function values were reduced (ejection fraction both 35% – Simpson method). Systolic pulmonary artery pressure was slightly elevated (42 mm Hg). As a result of heart team discussion, the patient was declared as surgically inoperable and qualified for consecutive transapical transcatheter aortic valve implantation – not suitable for a transfemoral approach – followed by transfemoral edge-to-edge repair of the tricuspid valve using the MitraClip system.
Both procedures were performed under general anesthesia using two- and three-dimensional transesophageal echocardiography (TEE) (iE 33, Philips Healthcare, Netherlands) and fluoroscopy guidance (Axiom Artis Zeefloor AXH 1604, Siemens, Germany). Unfractionated heparin was administered aiming at an ACT of 250–300 s throughout the procedure.
For the transapical TAVI (on October, 19th, 2015), the left ventricular apex was surgically exposed (small anterolateral minithoracotomy), an epicardial pacemaker probe (TME T bipolar, Osypka AG, Germany) was positioned, and the apical suture was prepared. The apex was then punctured and after balloon valvuloplasty (balloon catheter VACS II 28 × 40 mm, Osypka AG, Germany) (Figure 1)...


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