Percutaneous Transhepatic Mitral Valve Repair with the MitraClip System

Purpose: The femoral venous approach for percutaneous edge-to-edge repair of the mitral valve with the MitraClip system (Abbott Vascular, Santa Clara, CA) may not be possible in patients with occlusion or congenital anomalies of the inferior vena cava (IVC) or limited by the presence of an IVC filter. In these situations, the use of the percutaneous transhepatic venous access may be an alternative. Our purpose is to report the first to our knowledge MitraClip procedure using this approach.

Materials and Methods: After the patient signed the informed consent document, we performed a retrospective analysis of the medical record, collecting relevant data to elucidate the case.

Results: A 52-year-old woman presenting with New York Heart Association (NYHA) class IV symptoms caused by idiopathic dilated cardiomyopathy with an ejection fraction of 25%, and severe functional mitral regurgitation was referred for percutaneous mitral valve repair with the MitraClip system. The transfemoral venous access was initially attempted but found not to be feasible because of the presence of left-sided IVC continuing as the hemiazygos and azygos veins and draining into the superior vena cava and right atrium. At this point, the procedure was aborted, and a multislice computed tomography scan was performed, confirming the IVC anomaly and depicting the drainage of the normal-sized hepatic veins directly into the right atrium. Three days later, the MitraClip procedure was successfully accomplished using a percutaneous transhepatic approach. Four-month follow-up revealed NYHA functional class II symptoms and 1+ mitral regurgitation.

Conclusions: The percutaneous transhepatic venous access has been reported to be feasible and used in electrophysiology and diagnostic and interventional cardiovascular procedures in children and adults. This alternative approach might be useful for structural heart disease interventions requiring atrial septal crossing with large-sized catheters when access to the heart from the femoral approach is not possible.