“All in” or “Rien ne va plus”? First simultaneous catheter-based trivalvular treatment combined with atrial septal closure in a human

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 [1, 2]. Furthermore, successful transcatheter tricuspid valve edge-to-edge repair using the MitraClip system has recently been described for high-risk patients with tricuspid regurgitation [3]. This valvular dysfunction is mainly caused by right ventricular dilatation driven by volume or pressure overload secondary to heart failure, mitral disease and/or aortic valvular disease [4]. Thus, most of these patients suffer from multivalvular disease. However, simultaneous transapical TAVI and transfemoral clipping of the mitral as well as tricuspid valve with MitraClip completed by occlusion of an atrial septal defect has not been described so far. We report hereby this first-in-human intervention in a high-risk patient.
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, pleural effusions and stage III chronic kidney disease. Echocardiography revealed severe aortic stenosis (aortic valve area = 0.7 cm²) (Fig. 1). In addition, severe regurgitation of the tricuspid valve (effective regurgitation orifice area (EROA) = 0.88 cm²) and mitral valve (EROA = 0.44 cm²) with tethered leaflets was found (Fig. 2). Left and right ventricular function were reduced (ejection fraction of 50% and 35%, respectively). Elevated systolic pulmonary artery pressure could be documented (65 mm Hg).As a result of heart team discussion the patient was declared as surgically inoperable and qualified for transapical transcatheter aortic valve implantation – not suitable for a transvascular approach – followed by transfemoral edge-to-edge repair of mitral and tricuspid valves using the MitraClip system within one simultaneous procedure.
All interventions were performed on July, 4th, 2017 under general anaesthesia 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 activated clotting time (ACT) of 250–300 s throughout the procedure.
For the transapical TAVI the left ventricular apex was...


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