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An Innovative Solution to a Complex Problem

Even when mitral valve surgery is successful, sometimes serious complications can develop months later. That’s when the value of a talented group of colleagues really pays off.

H. Brandis Marsh, MD, a cardiologist at MedStar Washington Hospital Center since 1973 and a former director of the cardiac cath lab, had been monitoring for 10 years a 75-year-old Maryland man who had a worsening case of mitral valve regurgitation. When the patient’s ejection fraction dropped to nearly 40 percent, Dr. Marsh finally determined it was time for surgery. Dr. Marsh referred his patient to the experts at MedStar Heart & Vascular Institute (MHVI) for evaluation.

Ammar Bafi, MD, a cardiac surgeon at MHVI, scheduled surgery. He repaired the valve and placed a 34mm annuloplasty ring to stabilize it. The patient tolerated surgery well and returned home to recover.

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Zuyue Wang, MD, echocardiographer, and Lowell Satler, MD, interventional cardiologist, successfully repaired a mitral valve leak that was destroying the patient's red blood cells.

Several months later, the patient noticed his urine was a deep purple color. Because he had had a kidney stone previously, he attributed his symptoms to another kidney condition, so he first visited his urologist. He also saw Dr. Marsh the same day for a follow-up visit.

The two physicians discussed the case and were puzzled. They examined a urine sample under the microscope and found no red blood cells.

“This was a tipoff that the patient had hemolytic anemia,” Dr. Marsh says. But what was the cause?

The patient was referred to a hematologist. While doctors analyzed the problem, the patient received blood transfusions to combat his worsening condition.

In a subsequent visit to Dr. Marsh, the patient himself helped point them to the answer. He had done an Internet search and found several case reports of hemolytic anemia related to mitral valve repairs. “I’d never even heard of that,” Dr. Marsh says.

Zuyue Wang, MD, an echocardiographer at MHVI, performed a transesophageal echo (TEE), which showed a tiny leak had developed through the valve leaflets directed into a space around the valve ring.

“I knew there had to be a leak,” she says. “TEE confirmed my suspicion.” As new red blood cells went through the valve, they slammed into the ring, shearing and breaking up, destroying the cells completely. The leak itself was not significant, but the resulting hemolysis—a very rare occurrence—needed to be resolved.

A group of MHVI experts gathered to evaluate the problem and devise a solution. Surgery would normally be the answer to a problem of this nature, but all agreed that a second surgery was not the best option for this patient.

“We had operated only a few months before, and surgery is much more invasive the second time,” Dr. Bafi says. “If there was an option to solve the problem a different way, it would be much better for the patient.”

Fortunately, interventional cardiology provided a pathway to success. Lowell Satler, MD, director of the Cardiac Cath Lab at MHVI, was called in to review the TEE with Drs. Wang and Bafi. They briefly considered percutaneous placement of a plug in the space under the ring, but determined that the plug would displace a leaflet, and could make the leak worse.

So the team decided that a MitraClip® might be a better option. MHVI is one of the few centers that can place a MitraClip percutaneously, so the patient was in luck.

“I thought that placing a MitraClip was the patient’s best option,” Dr. Satler says. “This is a new treatment pathway for patients with complex problems such as this.”

In a transcatheter procedure, Dr. Satler left the mitral valve ring in place, and placed a clip to seal off the leak. During the procedure, Dr. Wang was in the catheterization lab, using TEE to guide the procedure each step of the way. “TEE draws a road map about how to get into the heart valve without damaging surrounding structures, and showed Dr. Satler where to put the clip,” Dr. Wang says.

The procedure went perfectly, and, while the patient was still on the table, his urine began to clear. By the next morning it was completely clear, a sure sign of success. He was discharged from the hospital the next day, and his condition has steadily improved. He is now considering a knee replacement.

This case demonstrates the value of a team of experts, all agree. “When you have people who know what they’re doing, they can attack a problem they’ve never seen before,” Dr. Marsh says.

“When you’re tackling structural-based heart disease, interventional cardiology offers innovative approaches,” Dr. Wang adds. “We’re not just fixing the plumbing, we can now fix the whole house.”

The patient, for his part, is very happy with the result. “I knew absolutely I was in the right hands,” he says. “This is a great place.”

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In a percutaneous procedure, Lowell Satler, MD, and Zuyue Wang, MD, used a MitraClip to repair a leak that developed after mitral valve replacement in a patient deemed too fragile for a second surgery.