More importantly, it is critical for excluding patients in whom MitraClip generally leads to inadequate results such as leaflet perforation, leaflet calcification, tethering or more than mild mitral stenosis. Procedureīaseline procedural imaging is important for accurate MV assessment and delineation of MR etiology and MitraClip placement strategy. Each of these handles allows for steering and directing the clip into separate direction (e.g., anterior, medial etc.) to allow for accurate positioning and clip delivery under TEE and fluoroscopy assessment. Unique features of the MitraClip allow for each mitral leaflet to be unilaterally engaged by a separate gripper and clip arm through a multi-step deployment sequence controlled by handles at the steerable guide, steerable sleeve or delivery handle. Specifically, the “valve-team” should have a uniform terminology to discuss the navigation of the MitraClip hardware based on navigational echocardiography with 2D transesophageal (TEE) and 3D live TEE with X-plane and 3D en-face views being the most common. Unlike transcatheter aortic valve replacement (TAVR) or surgical MV repair, the MitraClip procedures require a team approach between echocardiographic guidance and proceduralist to achieve a successful result. The MitraClip procedure at this point is usually divided into five separate procedural steps: (I) baseline imaging, (II) trans-septal puncture, (III) steering and positioning the MitraClip device, (IV) leaflet grasping, insertion assessment and deployment, and (V) post-release assessment, additional MitraClip placement and system removal ( 3). Preoperative prophylaxis antibiotics are administered per usual protocol. Patient is then prepped and draped in the usual fashion with exposure both groins. Invasive arterial monitoring was achieved via radial artery and large-bore venous access was inserted into right internal jugular vein. Patient was positioned supine in the hybrid operating room then general anesthesia was induced with endotracheal intubation. Patient was offered a MitraClip transcatheter mitral repair procedure as a viable alternative leading to decreased morbidity. While patient was amenable to surgical MV repair technically, her comorbidities and elevated STS mortality risk was 15.8% and morbidity was 66%. MR was severe with P2 prolapse, moderate annular dilatation and annular calcification (no mitral stenosis). Comorbidities include significant frailty, chronic renal failure (stage 3), prior non-ST elevation myocardial infarct (NSTEMI), diabetes, moderate chronic obstructive pulmonary disease, significant pulmonary hypertension and non-obstructive coronary artery disease (previous percutaneous coronary intervention).Įchocardiography reveals slightly reduced ejection fraction (50%) with moderate right ventricular dysfunction. Symptoms have progressed to New York Heart Association (NYHA) III classification which have limited her mobility and quality of life. By approximating the anterior and posterior leaflets together, the MitraClip mimics the ‘Alifieri stitch’ and achieves a double-orifice MV which reduces MR severity.Īn 84-year-old lady with severe symptomatic organic mitral regurgitation presents with increasing exertional dyspnea. Transcatheter mitral repair with the MitraClip System (Abbott Vascular, Santa Clara, CA) has been shown to be viable alternative to surgical mitral repair in patients with significant symptomatic degenerative mitral regurgitation (MR) with prohibitive surgical risk ( 1, 2).
Patients with myxomatous degeneration with prolapsing or flail mitral leaflets are usually amenable to sternotomy or minimally invasive mitral repair strategies that yield excellent short and long-term clinical outcomes with durable repair. Surgical mitral valve (MV) repair remains the gold-standard for organic primary MV pathology. Video Transcatheter mitral repair: MitraClip technique.
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