Treating Mitral Valve Prolapse in Barlow’s Disease by Creation of a Medial MitraClip Bridge and a “New” Lateral Orifice: Rationale for MitraClip NTR Adoption

J INVASIVE CARDIOL 2021;33(3):E227-E228. 

Key words: Barlow's disease, cardiac imaging, MitraClip implantation

In patients with Barlow’s disease, mitral valve pathology is multidimensional. Barlow’s disease is characterized by extensive mitral valve myxoid degeneration, chordae elongation, and mitral valve annular dilation leading to prolapse. Therefore, any strategy of percutaneous repair should consider increased mitral valve tissue frailty. Percutaneous mitral valve repair with MitraClip XTR (Abbott Vascular) has been proposed in patients with Barlow’s disease, as the extended length of the MitraClip XTR may facilitate “grasping” and limit the number of clips. However, the design of the MitraClip XTR includes arms that are 3 mm longer than those on the NTR device as well as 2 additional frictional elements, and requires patient selection based mainly on mitral valve tissue quality. We summarize our rationale for using the shorter and smaller MitraClip NTR in patients with Barlow’s disease.

(1) Due to tissue abundance in patients with Barlow’s disease, no elongated MitraClip arms are needed to simultaneously grasp both leaflets (Figure 1A).

(2) We start from the most medial part of the prolapse, close to the commissural tissue (fibrotic component) (Figure 1B).

(3) The first medial clip stabilizes the prolapsing valve. We proceed more centrally, close and parallel to the first clip, optimizing stress distribution (Figure 1C).

(4) Evaluation of residual mitral regurgitation (MR; must be less than second degree) and transmitral valve gradient (must be <5 mm Hg) is performed to confirm the possibility/necessity of additional clips.

(5) Multiple MitraClips may be necessary to stabilize the prolapse (Figure 1D).

(6) A new coaptation line through MitraClip bridge minimizes the risk of residual MR, creating a new lateral orifice (Figure 1D). 

From the Department of Cardiology, Vivantes Klinikum Am Urban and Klinikum im Friedrichshainm Berlin and University Medical Center, Rostock, Germany.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Ince reports personal fees from Abbott Vascular. The remaining authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 3, 2020.

Address for correspondence: Sebastian Feickert, MD, Department of Cardiology, Vivantes Klinikum Urban, Dieffenbachstraße 1, 10967 Berlin. Email: Sebastian.feickert@gmail.com