Μαρία Δρακοπούλου, Σοφία Βαïνά

Transcription

1 Μαρία Δρακοπούλου, Σοφία Βαïνά Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Νοσοκομείο

2 Spectrum of mitral regurgitation

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4 German Heart Report 2017 MitraClip implantations have numerically outperformed open-heart valve surgery during the last few years in Germany Munzel et al, EHJ, Volume 39, Issue 28, 21 July 2018

5 Greater Reach, Easier Grasping, And Improved Leaflet Capture

6 Morphological characterization for MitraClip eligibility Pathology in P1-P3 MVA>3cm 2 Length 7-10mm Flail size >15mm only in large mitral annulus Depth >11mm Wunderlich et al, European Heart Journal Cardiovascular Imaging (2013) 14,

7 Boekstegers P et al. Clin Res Cardiol (2014) 103:85 96

8 Second MitraClip? MVA can decrease by 50% by the first clip and by 30-40% with the 2 nd clip! PROS Better MR reduction Stronger/stable bridge Less MR relapse CONS Stenotic behavior Destabilization of 1stclip (SLA) Entanglement in chordae Leaflet distortion Longer procedure time Removal complications

9 No achievement of acute procedural success with placement of 1 st clip Residual MR is determined to be clinically unacceptable Majority of residual MR isolated to one side of 1st Clip Adequate MV area Transvalvular gradient < 8 mmhg (preferably less than 4 mm Hg) Adequate space to place second clip

10 Pre-procedural planning to decide approach One torn chord = one clip Broad MR jets = 2 or more clips Zipping from commissures toward middle Intra-procedural assessment of result Stenosis vs ρesidual MR

11 Should an additional clip be attempted? Should the additional clip be removed?

12 One more clip? Additional clip should be ok *Pressure ½ time is not validated for MitraClip Consider additional clip if necessary Mean MV gradient 3mmHg 4-5mmHg 6 mmhg Planimetered area >3cm 2 2-3cm 2 <2cm 2 P1/2t <80msec msec >110msec Done Consider removing depending on MR severity Mean MV gradient 7mmHg evaluate MVA Planimetered area <1.6cm 2 P1/2t >130msec

13 Main procedural steps for MitraClip implantation

14 Patient 71 years old with HCM, MV prolapse with moderate to severe MR, SAM and non-significant LVOT obstruction No previous cardiac surgery

15 Case 1 Transeptal puncture Main procedural steps for MitraClip implantation 3 echo steps 1. Tenting in the bicaval view 2. Tenting in short axis view 3. Tenting in 4-chamber view (0 ) (height)

16 Case 1 Transeptal puncture Main procedural steps for MitraClip implantation 3 echo steps 1. Tenting in the bicaval view 2. Tenting in short axis view 3. Tenting in 4-chamber view (0 ) (height)

17 Case 1 Introduction of SGC into LA Main procedural steps for MitraClip implantation

18 Case 1 Advancement of the CDS into LA Main procedural steps for MitraClip implantation

19 Case 1 Steering and positioning of the MitraClip above MV Main procedural steps for MitraClip implantation

20 Case 1 Advancing the MitraClip into the LV Main procedural steps for MitraClip implantation

21 Case 1 Grasping the leaflets and assessing for proper position Main procedural steps for MitraClip implantation

22 Case 1 Grasping the leaflets and assessing for proper position Main procedural steps for MitraClip implantation

23 Case 1 Release Main procedural steps for MitraClip implantation

24 Case 1 The orientation of the second clip is mostly done fluoroscopically and should be aligned as parallel as possible to the first clip.

25 Case 1 During advancement of the MitraClip from the LA into the LV, the clip should be closed - to avoid any interference or entanglement with the chordae tendineae- and then re-opened in the LV. Folding of leaflet tissue between two MitraClips should be avoided as this may cause uncorrectable residual MR

26 Case 1 Second clip Main procedural steps for MitraClip implantation

27 Case 1 Second clip Main procedural steps for MitraClip implantation

28 Case 1 Second clip Main procedural steps for MitraClip implantation

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31 Case 2 Patient 82 years old female with NYHA III despite OMT, severe MR due to degenerative MV disease (prolapse) CAF TR +2/4, leadless PCM for symptomatic bradycardia

32 Case 2

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34 Changes in strategy depending on the behavior of the MR after positioning the first clip in a central position. Predictive value of the VC for the need of more than 1 clip. ROC curve represents the accuracy of the VC measurement as a predictor of the need for more than 1 MitraClip Alegria-Barrero E et al, EuroIntervention Feb;9(10):

35 Patients in MC group had larger mitral valve (MV) annuli (P<0.025), MV orifice areas (MVOA) (P<0.01), and MR degree (P <0.005). Paranskaya et al, Catheterization and Cardiovascular Interventions 81: (2013)

36 The indication to use multiple clips should be supported by the MR hemodynamics and MV anatomy The decision should be rationalized preoperatively and confirmed or modified intraoperatively The clipping by multiple clip strategy is started at the postero-medial commissure (A3- P3) toward the antero-lateral one (A1-P1). In some patients this goal can be achieved using MC with minimized risk of MV stenosis if preoperative anatomy/mechanism of MV regurgitation are adequately assessed.

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