Routine MitraClip. Image Guidance Step by Step
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1 Routine MitraClip Image Guidance Step by Step Douglas C. Shook, MD, FASE Director, Cardiothoracic Anesthesia Fellowship Director, Cardiac Interventional Anesthesia Department of Anesthesiology BRIGHAM AND WOMEN S HOSPITAL Heart & Vascular Center HARVARD MEDICAL SCHOOL TEACHING HOSPITAL
2 Disclosures Sorin - Speaker Edwards Lifesciences - Speaker
3 Objectives By the end of the presentation, the viewer will be better able to... understand the mitral anatomy as it applies to MitraClip placement. describe the key imaging steps for MitraClip placement. apply an anatomic approach to transesophageal echocardigraphic imaging for MitraClip placement.
4 The MitraClip Procedure
5 The MitraClip Procedure
6 The MitraClip Procedure
7 Ideal Valve Morphology MR originating at A2/P2 (degenerative or functional) Lack of Ca++ in grasping area MVA > 4cm 2 PMVL > 10mm length Flail width <15mm Flail gap <10mm Sufficient tissue for grasping Coaptation depth <11mm Coaptation length >2mm
8 Assessment
9 Assessment
10 Assessment
11 Assessment
12 Assessment
13 Parallax in 3D Imaging
14 Parallax in 3D Imaging
15 Assessment
16 Planning the MitraClip Approach?
17 Planning the MitraClip Approach? Where is the optimal transseptal puncture?
18 Planning the MitraClip Approach? Where is the optimal transseptal puncture? Where do you place this clip?
19 Planning the MitraClip Approach? Where is the optimal transseptal puncture? Where do you place this clip? How do you orient the clip relative to coaptation?
20 Planning the MitraClip Approach? Where is the optimal transseptal puncture? Where do you place this clip? How do you orient the clip relative to coaptation? How do you place the clip there while avoiding the subvalvular apparatus?
21 Planning the MitraClip Approach? Where is the optimal transseptal puncture? Where do you place this clip? How do you orient the clip relative to coaptation? How do you place the clip there while avoiding the subvalvular apparatus? What papillary muscle do the ruptured chords come from?
22 Planning the MitraClip Approach? Where is the optimal transseptal puncture? Where do you place this clip? How do you orient the clip relative to coaptation? How do you place the clip there while avoiding the subvalvular apparatus? What papillary muscle do the ruptured chords come from? How do you grasp the leaflets once you re there?
23 Planning the MitraClip Approach? Where is the optimal transseptal puncture? Where do you place this clip? How do you orient the clip relative to coaptation? How do you place the clip there while avoiding the subvalvular apparatus? What papillary muscle do the ruptured chords come from? How do you grasp the leaflets once you re there? How many clips will be needed to adequately reduce the MR
24 Procedural Steps for MitraClip Transseptal puncture Introduction of the steerable guide catheter into the left atrium Advancement of the clip delivery system into the left atrium Positioning the clip above the mitral valve Advancing the clip into the left ventricle Grasping the leaflets and assessing for insertion MR and MS evaluation Clip detachment and assess need for additional clips Assess for pericardial effusion and other complications
25 Septal Puncture - MitraClip Inf Sup Post Ant Superior Posterior Location
26 Transseptal Puncture Superior and Posterior Location 4-5 cm above the MV annulus
27 Transseptal Puncture Text
28 Dist 3.30 cm Text
29 Transseptal Puncture Text
30 Dist 4.34 cm Text
31 Crossing the Septum
32 Crossing the Septum
33 ME Commissural View P1 P3 A2 Post Pap Ant Pap 0 (40-80 ) Ant PM Post PM
34 ME Commissural View 0 (40-80 ) Ant PM Post PM
35 ME Long Axis View 0 ( ) LA AV LVOT Inf Lat Wall Ant Sept Wall No PM
36 ME Long Axis View 0 ( ) No PM
37 AV P1 A1 A3 P3 A2 P2 P2 Ant Pap LVOT Post Pap
38 MitraClip Positioning AV
39 Positioning the Clip
40 Positioning the Clip AV
41 Positioning the Clip
42 Positioning the Clip AV
43 Positioning the Clip
44 Positioning the Clip AV
45 Positioning the Clip
46 Positioning the Clip AV
47 Positioning the Clip
48 Positioning the Clip AV
49 Positioning the Clip
50 Positioning the Clip AV
51 Turn Down the Gain
52 Turn Down the Gain AV
53 Clip Below the Valve in the LV
54 Clip Below the Valve in the LV
55 Grasping the Leaflets
56 Grasping the Leaflets
57 Releasing the Clip Measured Orifice > 1.5 cm 2
58 Releasing the Clip
59 Releasing the Clip
60 Gradients Lateral Orifice Medial Orifice Mean Gradient < 5 mmhg
61
62 Pulmonary Veins Before After
63 Procedural Steps for MitraClip Transseptal puncture Introduction of the steerable guide catheter into the left atrium Advancement of the clip delivery system into the left atrium Positioning the clip above the mitral valve Advancing the clip into the left ventricle Grasping the leaflets and assessing for insertion MR and MS evaluation Clip detachment and assess need for additional clips Assess for pericardial effusion and other complications
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