mitraclip procedure a to z
DESCRIPTION
Invited lecture at EuroPCR 2009 on the Mitraclip Procedure (Barcelona 2009). It describes the procedure step-by-stepTRANSCRIPT
Francesco Maisano MD
Oct 23Oct 23rdrd 2008 2008Functional MR ptFunctional MR ptSan Raffaele HospitalSan Raffaele HospitalEquipeEquipe
Maisano, Michev, La Canna, Maisano, Michev, La Canna, Alfieri, ColomboAlfieri, Colombo
66 yo, male, 64 Kg, 164 cm, BSA 1.7 m2, BMI 24
Post-ischemic Cardiomyopathy, CCS II, NYHA III
Comorbidities
Infrarenal abdominal aneurysm
2006 stenting of right common carotid artery and right internal carotid artery
2005 Bone Marrow Tx for AML
1994 anterior AMI; 2001 PCI followed by CABG (LIMA—LAD), followed by multiple
PTCA with DES
1/2008: AMI for intrastent thrombosis -> POBA on LAD
4/2008 Acute Pulmonary Edema CRT with Biventricular Pacing and ICD
Log ES: 45%; STS risk 20%
Dilated ischemic cardiomyopathy LVEDV: 211ml LVESV: 165 ml
Severe LV dysfunction (EF 20%)Severe MR (ERO 0,2 cm2) Severe tethering
▪ TA 4,1 cm2; CD 1,7 cm
Annular dilatation▪ SL 38 mm; IC 46 mm);
Severe Pulmonary Hypertension (75mmHg), RV failure, Moderate tricuspid regurgitation
Central MR MR jet width below
1.5 cm Coaptation length >3
mm Coaptation depth 1.7
Right femoral vein access Right femoral vein access with a 6F introducerwith a 6F introducer
Left femoral artery with a 6 F Left femoral artery with a 6 F introducerintroducer Pigtail in the ascending aortaPigtail in the ascending aorta
Standard transeptal Standard transeptal puncture setuppuncture setup
Line ofcoaptation
3.5 cm3.3 cm
Extra Stiff Amplatz exchange length wire (.035”) in upper PV or large loop in LA through the Mullins sheath
CoilsCoils
Guide Marker
LA
RA
Guide Marker
AmplatzGuide
Requires a Controlled, Systematic & Requires a Controlled, Systematic & Iterative approachIterative approach
Imaging guidanceImaging guidance Primarily Echocardiography (aided by Primarily Echocardiography (aided by
Fluoroscopy)Fluoroscopy) 3-D positioning using 4 key echo views 3-D positioning using 4 key echo views
▪ LVOT and (Inter-) Commissural viewsLVOT and (Inter-) Commissural views▪ SAX at base and TG-SAX viewsSAX at base and TG-SAX views
Position adjustmentsPosition adjustments Multiple “controls” availableMultiple “controls” available
▪ Knobs; Torque; TranslationKnobs; Torque; Translation
Soft tip of guide
Clip
Guide Marker
SleeveMarkers
Guide
Steerable sleeve
Clip delivery handle
Stabilizer
Atrial Septum
Guide
Steerable sleeve
Clip delivery handle
Stabilizer
Atrial Septum
A high risk surgical candidate has been submitted to Mitraclip procedure to treat FMR
The patient was transferred from ICU to the general ward in day 1 and discharged home 4 days after the procedure
At 3 months the MR reduction is stable with mild residual MR, reduction of LV volumes, and the patient is in NYHA class II