Discussion
TMVR systems are becoming increasingly popular as they represent a potential solution for high-risk and inoperable patients with MR. Percutaneous mitral leaflet repair with the Mitraclip (Abbot Vascular, Santa Rosa, CA) has revolutionized TMVR, but it is far from providing a stand-alone solution to FMR with mitral annular dilatation as the leading pathology. It has been advocated that the absence of a concomitant annuloplasty long term may result in an inadequate reduction or recurrence of regurgitation in patients with FMR. The Cardioband is a transcatheter direct annuloplasty device implanted transvenously, transseptally in patients with FMR in case surgical and medical treatment options are limited.
Since the first-in-man implantation of the Cardioband, a few studies have reported safety, efficacy and the short-term results of the technique [5, 6]. In a multicenter study, Zeitoun et al. reported 1 year outcomes of the system with a technical success rate of 97%. Partial device dehiscence due to anchor disengagement was reported in 16.6% of patients immediately after implantation [5]. Eschenbach et al. has also reported an anecdoatal explantation of the Cardioband three days after the intervention [4].
In the presented patient, although a detachment of one of the anchors was found already during the procedure, two more dehiscent anchors were confirmed during the operation. This may have resulted from “unscrewing” of the anchors over time under high tension during cardiac contractions, especially at the P2 segment where annular displacement has the highest amplitude. This challenging problem may be overcome with procedural modifications such as increasing the number of implanted anchors at this segment.
The Cardioband is a promising device for TMVR in patients at high surgical risk. However, the lack of long-term results and the limited short-term reports with several complications might discourage surgeons and interventionalists from wide adoption. Mitral surgery after Cardioband implantation is technically demanding as anchor removal from the mitral annulus is not easily accomplished. A longer interval between the implantation and explantation of the device makes surgical explantation more challenging due to the risk of a potential complication during removal of the highly-endothelized device. In these cases, care must also be taken to prevent damage to adjacent structures. We believe that the suggested “cut and unscrew” technique may reduce the risk of procedure related complications..