ΔΙΑΔΕΡΜΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΔΟΜΙΚΩΝ ΠΑΘΗΣΕΩΝ: Ο ΡΟΛΟΣ ΤΗΣ ΑΠΕΙΚΟΝΙΣΗΣ ΣΤΟ ΑΙΜΟΔΥΝΑΜΙΚΟ ΕΡΓΑΣΤΗΡΙΟ ΣΤΗΝ ΤΟΠΟΘΕΤΗΣΗ MITRACLIP

Transcription

1 ΔΙΑΔΕΡΜΙΚΗ ΑΝΤΙΜΕΤΩΠΙΣΗ ΔΟΜΙΚΩΝ ΠΑΘΗΣΕΩΝ: Ο ΡΟΛΟΣ ΤΗΣ ΑΠΕΙΚΟΝΙΣΗΣ ΣΤΟ ΑΙΜΟΔΥΝΑΜΙΚΟ ΕΡΓΑΣΤΗΡΙΟ ΣΤΗΝ ΤΟΠΟΘΕΤΗΣΗ MITRACLIP ΒΛΑΣΗΣ ΝΙΝΙΟΣ MD MRCP ΚΛΙΝΙΚΗ ΑΓΙΟΣ ΛΟΥΚΑΣ ΘΕΣΣΑΛΟΝΙΚΗ

2 CONFLICT OF INTEREST PROCTOR FOR MITRACLIP ABBOTT VASCULAR

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4 MitraClip Gripper Lever Actuator Knob Lock Lever Arm Positioner Knob Arm Clip delivery system Gripper Steerable guide handle Delivery catheter handle Steerable guide, sleeve and catheter Stabilizer MitraClip Device

5 TEE and 3D TEE is absolutely essential Patient screening and selection (even at the time of the procedure) Procedural guidance Assessment of the result Diagnosis of complications

6 EVEREST Criteria Feldman T et al., J Am Coll Cardiol 2009;54:686 94

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9 Mitral valve anatomy Anterior annulus Anterior leaflet Posterior leaflet Posterior annulus Chordae tendineae Lateral papillary muscle Medial papillary muscle The mitral valve apparatus includes the annulus, the leaflets, the chordae tendineae, and papillary muscles. modified from Carpentier, A. et al. Carpentier s Reconstructive Valve Surgery. Saunders Elsevier; The leaflets are normally asymmetric the anterior leaflet has a larger surface area, but occupies a smaller amount of annular circumference. (Foster GP et al. Accurate localization of mitral regurgitant defects using multiplane transesophageal echocardiography. Ann Thorac Surg 1998) 9

10 0 Views to Obtain Superior: 5 Ch view with A1/P1 of the mitral valve (MV) clearly visualized This view is obtained at the mid-esophageal level The aortic valve and left ventricular outflow tract are clearly visualized The LV is foreshortened Central: 4 Ch view with A2/P2 clearly visualized Advanced probe 1-3 cm The LV cavity is more completely visualized For functional MR, coaptation length should be measured and for degenerative MR flail gap should be measured if present Inferior: 4 Ch view with A3/P3 clearly visualized The probe is further advanced 1-3 cm The coronary sinus and tricuspid valve may be seen

11 60-90 Views to Obtain Anterior This view is obtained at the anterior side of the valve to visualize A1, A2 and A3 scallops Midline This view is obtained at the midline of the valve to visualize P1, A2 and P3 scallops Posterior This view is obtained at the posterior side of the valve to visualize P1, P2 and P3 scallops

12 60-90 Views: Anterior The anterior leaflet can be isolated by rotating the probe clockwise from the midline The LAA may be visualized Shows A1, A2 and A3 scallops

13 60-90 Views: Midline Shows P1, A2 and P3 scallops The midline of the MV Note that the chordal attachments and the papillary heads are visualized

14 60-90 Views: Posterior Shows P1, P2 and P3 scallops The posterior leaflet can be isolated by torquing/rotating the probe counterclockwise from midline Note that the LAA is no longer in view and the chordae are not visualized completely

15 Views to Obtain Lateral This view is obtained at the lateral side of the valve to visualize A1 and P1 scallops Central This view is of the central aspect of the valve with A2 and P2 scallops clearly visualized Medial This view is obtained at the medial side of the valve to visualize A3 and P3 scallops

16 Views: Central Shows A2 and P2 scallops Visualize entire ascending aorta The anterior leaflet is at its longest

17 Views: Medial Shows A3 and P3 scallops Torquing/rotating the probe clockwise from central will expose the medial aspect of the MV

18 Pulmonary Vein Views Left Upper Pulmonary Vein (0-30 ) Use color flow and PW Doppler Place PW Doppler sample volume 1-2 cm into PV Right Upper Pulmonary Vein ( ) Use color flow and PW Doppler Place PW Doppler sample volume 1-2 cm into PV Rotate probe posterior (clockwise) from bicaval view to visualize the RUPV Pulmonary Vein Flow Adjust scale/baseline to visualize antegrade and retrograde flow

19 View: Bicaval This procedural view demonstrates the IVC, SVC, atrial septum, right and left atria Analysis: Fossa: Target zone

20 15-45 View: Short Axis at Base This procedural view demonstrates a cross-section of the aorta, atrial septum, right and left atria Analysis: Fossa: Target zone RA & LA Size Aortic Valve

21 0-20 View: Transgastric Short Axis Adjust angle to optimize SAX with both anterior and posterior leaflets clearly visible Measure flail width if present Use color flow Doppler to demonstrate jet origin Jet Origin Degenerative: Drop out Location MV Orifice Area

22 0-20 View: Transgastric Short Axis

23 Live 3D surgical view P1 P2 P3 Push forward Pull back Torque clockwise Torque c/clockwise Towards the anterolateralcommissure Towards the posteromedialcommissure Move posteriorly Move anteriorly 23

24 Additional Assessments Anatomic Measurements in Degenerative Mitral Regurgitation (DMR) Flail Gap, Flail Width Functional Mitral Regurgitation (FMR) Vertical Coaptation Length Confirm central jet origin: A2/P2 Measure and confirm mitral valve area Absence of calcification in the grasping area

25 Flail Gap (DMR) Flail gap is defined as the greatest distance between the ventricular side of the flail leaflet segment to the atrial side of the opposing leaflet edge This distance is measured perpendicular to the plane of the annulus in two views and the largest measurement is used The TEE views for measurement are the: 4 Chamber long axis (LAX) LVOT Measure Flail Gap during Systole

26 Flail Width (DMR) Flail width is defined as the width of flail leaflet segment as measured along the line of coaptation in the transgastric short axis view TEE View for measurement is transgastric SAX Measure during systole

27 DMR Flail/Prolapse Width This measurement can also be made along the line of coaptation in the intercommissural view

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29 Vertical Coaptation Length (FMR) Vertical coaptation length is defined as the vertical length of leaflets that is in contact, or is available for contact, during mid-systole in the atrial-to-ventricular direction. This measures the length of leaflet tissue available to be inserted into the arms of the MitraClip Device. The TEE view for measurement is the: 4 Chamber Simultaneous color and non-color views are helpful Color views of both the proximal convergence zone in the ventricle and regurgitant jet in the atrium confirm location of the regurgitant lesion. Non-color views are used to measure the coaptation length at the regurgitant lesion.

30 Anatomic Measurements

31 Sufficient Echo Views Silvestry FE et al., J Am Soc Echocardiogr 2007;20:

32 Sufficient RT3D TEE quality Not mandatory Normally good RT3D TEE quality follows good 2D TEE quality

33 X plane Simultaneous biplane view LVOT 2ch LVOT 2ch 33

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37 Transseptal puncture

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41 Transseptal puncture Superior and posterior in the atrial septum Bi caval ( ) SAX at Base (30-60 ) 4-Chamber view superior inferior "tenting" location Anterior posterior "tenting" location working space Above the valve?

42 Pull-Back Technique Echo view: Bi-caval Tenting Superior Inferior aspect of fossa 42

43 Transseptal puncture: A-P positioning (SAX view) POSTERIOR P2 P LATERAL Line of coaptation A2 A1 LAA P3 A3 MEDIAL FOSSA Aorta ANTERIOR Too far anterior

44 Transseptal puncture: A-P positioning (SAX view) POSTERIOR P2 P LATERAL Line of coaptation A2 A1 LAA P3 A3 MEDIAL FOSSA Aorta ANTERIOR More posterior closer to LOC

45 Tenting Superior Aspect of Fossa Echo view: 4 Chamber or 5 Chamber, Height cm 3.5 cm 45

46 CASE 71 Y. OLD MALE CABG PREVIOUS MI REFRACTORY HEART FAILURE, PULMONARY OEDEMA FOR 4 WEEKS

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67 Assessment of the result What result is considered acceptable?

68 Flail P2-56 y. old man

69 Result: almost perfect

70 Flail P2 87 y. old man

71 Result adequate

72 FMR 80 y old in NYHA IV and Right Heart Failure

73 Moderate MR after 2 clips Patient had tremendous improvement

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75 65 y old Ischemic MR BASELINE MR AFTER ONE CLIP (BB 95/70)

76 65 y old Ischemic MR AFTER ONE CLIP (BP 130/70) AFTER 2 CLIPS (BP 150/85)

77 75 YEAR OLD FMR

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82 RESHAPE-HF2 TRIAL RANDOMISED INVESTIGATION OF THE MITRACLIP DEVICE IN HEART FAILURE: 2 ND TRIAL IN PATIENTS WITH CLINICALLY SIGNIFICANT FUNCTIONAL MITRAL REGURGITATION

83 Objective To study the safety and effectiveness of the MitraClip System in the treatment of clinically significant functional mitral regurgitation in symptomatic patients with chronic heart failure in NYHA Functional Class II, III or IV. 1 Objective and Background

84 Key Inclusion Criteria (1) Age between 18 years and 90 years old. Clinically significant FMR (moderate-to-severe or severe) as defined by European Association of Echocardiography, within 90 days prior to randomization. Optimal standard of care therapy for heart failure, according to current ESC/HFA guidelines with no dose changes of heart failure drugs (with the exception of diuretics) during the last 2 weeks prior to randomization. (Note: Significant dose changes are considered to be present, if a new drug class was started or when the dose of an exisiting drug class was increase >100%) 3 Pre-Randomization

85 Key Inclusion Criteria (2) NYHA Class II, III or IV, despite optimal standard of care therapy, within 30 days preceding randomization. Hospitalization for heart failure (acute care admission or emergency room visit) within 12 months preceding randomization BNP 300 pg/ml or NT-proBNP 1000 pg/ml within 90 days preceding randomization. OR (Note: BNP or NT-proBNP must be obtained after the subject has been stabilized on optimal therapy and has undergone revascularization and/or CRT, as appropriate) 3 Pre-Randomization

86 TWO CENTERS IN GREECE ΤΜΗΜΑ ΔΙΑΔΕΡΜΙΚΩΝ ΒΑΛΒΙΔΙΚΩΝ ΠΑΘΗΣΕΩΝ- ΥΓΕΙΑ ΑΘΗΝΑ ΚΛΙΝΙΚΗ ΑΓΙΟΣ ΛΟΥΚΑΣ-ΘΕΣΣΑΛΟΝΙΚΗ δωρεαν

87 CONCLUSIONS 3D TEE is essential in guding a mitraclip procedure Valuable in patient selection, guiding every step of the procedure, assessing the result and early diagnosing the complications. Close collaborations between the interventional Cardiologist and the ECHO-Cardiologist is mandatory. Carefully assess the hemodynamics as the patient is sedated.