Hemodynamic Tracing of an Eccentric Jet in Severe Mitral Regurgitation During Edge-to-Edge Repair

An 89-year-old woman presented for mitral valve edge-to-edge repair for severe mitral regurgitation (MR). At baseline, she had a degenerated mitral valve with a flail P2 leaflet along the lateral edge of A2P2 and marked posterior annulus calcification. Invasively, the left atrial V-wave was 80 mm Hg, which improved to 33 mm Hg after a MitraClip NT (Abbott) was implanted on A2P2. Transesophageal echocardiogram images showed persistent severe MR, with a residual eccentric jet noted on the lateral aspect of the valve (Figure 1A). The hemodynamic tracing (Figure 1B) was obtained as the guide catheter was moved medially, away from the lateral annulus, where the residual jet was located (Figure 1C). This tracing exemplifies the importance of the catheter position in the atrium when pressures are being obtained. It is not uncommon to observe a discrepancy between the results obtained from color Doppler imaging and the corresponding hemodynamic changes as many patients exhibit a residual color jet despite a significant reduction in V-wave and mean left atrial pressure, as illustrated in our case, from 38 to 20 mm Hg. (Figure 1D). This is largely attributed to sampling errors and must be carefully considered when assessing the effectiveness of percutaneous mitral repair, particularly in cases where eccentric jets are difficult to visualize and hemodynamically evaluate. Therefore, a combination of multiple parameters should be utilized in these cases. In this instance, the decision was made to implant a second clip. However, attempts to grasp the flail leaflet lateral to A2P2 were unsuccessful due to insufficient leaflet integrity, which resulted in severe residual MR. Pearls in Hemodynamics from editors Larry S. Dean, MD, and Morton J. Kern, MD•Appropriate invasive hemodynamics requires the correct catheter position in the cardiac chamber to be assessed.•Incorrect catheter placement can lead to erroneous information and conclusions, which can impact patient care decisions.•When the hemodynamic assessment is discordant with the clinical presentation, one should reevaluate and not assume the measured hemodynamics are always error free. •Appropriate invasive hemodynamics requires the correct catheter position in the cardiac chamber to be assessed.•Incorrect catheter placement can lead to erroneous information and conclusions, which can impact patient care decisions.•When the hemodynamic assessment is discordant with the clinical presentation, one should reevaluate and not assume the measured hemodynamics are always error free. Pedro Villablanca is a consultant for Edwards Lifesciences, Abiomed, AngioDynamics, and Teleflex. Tiberio Frisoli is a proctor for Edwards Lifesciences, Abbott, Boston Scientific, and Medtronic. William O’Neill has served as a consultant for Abiomed, Edwards Lifesciences, Medtronic, Boston Scientific, Abbott Vascular, and St. Jude Medical; and serves on the board of directors of Neovasc. Dee Dee Wang is a consultant to Edwards Lifesciences, Abbott, NeoChord, and Boston Scientific and receives research grant support from Boston Scientific assigned to employer Henry Ford Health System. Brian O’Neill is a consultant to and receives research support from Edwards Lifesciences. All other authors report no relevant financial disclosures. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.