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MitraClip CasesSunil Mankad, MD, FACC, FCCP, FASE
Associate Professor of MedicineMayo Clinic College of Medicine
Director, Transesophageal EchocardiographyAssociate Director, Cardiology Fellowship
Mayo Clinic, Rochester, MNACC Governor, [email protected]
@MDMankad
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DISCLOSURE
Relevant Financial Relationship(s)None
Off Label UsageNone
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Case 1• 86 year old female• Acute onset dyspnea from pulmonary edema• History of prior CABG• CKD (creatinine 2.0 mg/dl)• Paroxysmal atrial fibrillation• Physical exam
– 3/6 holosystolic murmur• TTE
– Flail MV with severe mitral regurgitation– LV EF 60%
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CXR
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EKG
• Catheterization: Patent Grafts
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TEE
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TEE: Flail MV Posterior LeafletA1-P1/lateral portion of P2
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TEEA2-medial portion P2 A3-P3
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TEE: Commissural View
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TEE
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TEE
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3D TEE: View from LA
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Mitral Valve• Mean Gradient 5 mmHg at HR of 88 BPM• Valve area >4.0 cm2
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Heart Team Discussion• CV Surgery, Valve/Imaging Specialist, and
Structural Interventionalist→ Decision made to proceed with MitraClip
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Procedural TEE: Flail P2 (Lateral Portion)
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Transeptal Puncture
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Sheath in Left Atrium
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MitraClip Device in Left Atrium
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MitraClip Device Toward MV
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Heading Toward Valve
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Importance of Clip OrientationWrong Correct
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Grasping MV
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MV Grasped
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MV Grasped
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Final Result: Mild MR
Mean Gradient 5 at HR 77 BPM
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Final 3D Images
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Pre-clip
Post-clip
Left Atrial “V” wave Tracings
45 mmHg
15 mmHg
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Atrial Septum: Small ASD
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Pre-discharge TTE: Mild MR
→ Mean Gradient 3 at HR 59 BPM
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Outcome• Patient discharged home 4 days post-
procedure• Dyspnea markedly improved• Continues to do well 18 months post-
procedure
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Case #2• 81 year old male with PMH of 3 vessel
CABG 20 years prior– Inferior MI 2 years ago → PCI to RCA SVG – Recent Patent SVG to OM1, patent LIMA to
LAD, and patent RCA• LV EF 51 %
– inferior regional wall motion abnormality• Severe “functional” mitral regurgitation• Progressive dyspnea over last 1 year
– NYHA class III
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TTE
ERO (PISA);0.39 cm2
Regurgitant volume (PISA);57 cc
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81 year old with severe ischemic (functional) MR
• Recurrent hospitalizations despite optimal medical therapy– Quality of life diminishing
• Multidisciplinary Heart Team Evaluation• Discussion with patient
– MitraClip
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Procedural TEE
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Procedural TEE
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Procedural TEE
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Procedural TEE
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Procedural TEE
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3D LA View
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3D LV View
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3D Color DopplerLA View LV View
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No Mitral Stenosis
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Transeptal Puncture
3.85 cm
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Device Across Atrial Septum
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Guiding Toward MV
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MV Grasped
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Color with MV Grasped
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3D Color with MV Grasped
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Decision Made to Place 2nd MitraClip
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2nd MitraClip in Place with Grasped MV Leaflets
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2nd MitraClip with Grasped MV Leaflets → Improved MR
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3D Color After 2nd Clip
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Gradient after 2nd Clip
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Small ASD Post-Procedure
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Outcome• Patient extubated• Much less dyspnea 1 day later• Discharge to home
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1 Month Follow-up TTE
SIX-MINUTE WALK DATATotal time walked: 6 minutesTotal distance walked: 1400 feet; 426.7 meters, which is 99% for age and gender.Rest Stops: NoO2 usage: None
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Case #389 year old man with dyspnea• Very active (digs potatoes) but gets quite
short of breath• Flail mitral leaflet noted 1.5 years prior• Past History:
– HTN– CKD stage 4 (Cr 2.0)– Depression– OSA on CPAP– Anemia of chronic disease– Spinal stenosis s/p surgery
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• 1.5 years ago: exertional dyspnea and chest discomfort
• LVEDD: 60mm, LVESD: 35 mm• EF: 69%, RVSP 57 mmHg• Flail posterior leaflet w/severe MR• Conservative management
recommended to avoid surgery
89 year old man with dyspnea
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• Physical Examination:– HR 49, BP 126/78, BMI 36– Normal JVP– Decreased breath sounds in bases– Laterally displaced PMI, 3/6 blowing holosystolic
murmur at apex– Abdomen soft, nondistended, no hepatomegaly– 2+ bilateral lower extremity pitting edema
• Laboratory Data:– Hgb 9.4– Cr 1.9– NT pro BNP 5681
89 year old man with dyspnea
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89 year old man with dyspnea
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Transthoracic Echocardiogram
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Severe Eccentric MR
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TEE: Flail P2
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89 year old man with dyspnea• 6 minute walk: 213 m, 65% predicted• STS risk 6.7% repair, 8.5% replacement• Not Frail• CV Surgery: high risk• Heart Team Discussion
– MitraClip Recommended
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TEE-guided Transseptal
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Leaflets Grasped
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Grasp Confirmed: Multiple Views
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MitraClip Deployed: Mild Residual MR
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3D TEE
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3D Color TEE: Single Beat
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Pre Post
60 mmHg 40 mmHg
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Small Residual ASD
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• Postprocedure:– Extubated uneventfully– Discharged to home the next day
89 year old man with dyspnea
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89 year old man with dyspnea30 day f/uBaseline
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• 30 day follow-up: dyspnea resolved• 6 min walk: 277 m, 83% predicted• Participating in cardiac rehab• TTE: LVEDD 57mm, LVESD 37 mm• EF: 68%• RVSP: 56 mmHg• NT pro BNP 1714
Case #389 year old man with dyspnea
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Follow-up TTE
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Follow-up TTE
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Follow-up TTE: Mild MR
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Backup Slides
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MitraClip Procedure
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MitraClip Device
Beigel R...Siegel RJ, MD. J Am Coll Cardiol 2014;64:2688–700(Images provided courtesy of Abbott Vascular ª 2014. All rights reserved.)
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Loosen
Torque
3-D Navigation System
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EVEREST II Trial 4 Year Results
• No difference in 3-4+ MR• No difference in death or repeat surgery
Mauri L et al. JACC 2013; 62:317-328.
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Recommendations COR LOEPercutaneous MV repair may be considered for severely symptomatic patients (NYHA class III-IV) with chronic severe primary MR (stage D) who have a reasonable life expectancy, but a prohibitive surgical risk because of severe comorbidities
IIb B
2014 ACC/AHA Guidelines Percutaneous Mitral Valve Repair
Nishimura RA et al. JACC 2014; 63:e57-e185.
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TVT OutcomesN =564
• Procedure success….• Complications............• Length-of-stay............• Home discharge.........
91.8%7.8%3 d (1.6 d)81.9%
Sorajja P et al. ACC Scientific Sessions 2015 (unpublished)
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Adverse Events• In-hospital mortality……………..…….• 30-day mortality…………………………• Cardiac surgery…….....………….…….• Stroke……………………………..………• Myocardial infarction……………...……• Major bleeding………………….….……• Cardiac perforation……………….……• Device-related events……………..…...• Single leaflet device attachment....• Device embolization…………..……• Other…………………………….….…
2.3%5.8%0.5%1.8%0%
3.9%0.7%2.7%1.1%0.4%1.2%
Sorajja P et al. ACC Scientific Sessions 2015 (unpublished)
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0%
20%
40%
60%
80%
100%
Baseline Post-implant
Grade 4
Grade 3
Grade 2
Grade 1
Mitral Regurgitation
Change in Mitral RegurgitationClip implantation occurred in 94%
93% MR ≤2
63.7% MR≤1
p<0.001
Sorajja P et al. ACC Scientific Sessions 2015 (unpublished)
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Transseptal PunctureImaging: Bi-caval, X-Plane
• Pull-Back Technique
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Transseptal PunctureImaging: 4-Chamber or 5 Chamber
3.5 - 4.0 cm3.5 - 4.0 cm
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Transseptal PunctureShort Axis at the Base → Posterior Direction
RA
LA
AO
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Transeptal Puncture by 3D Echocardiography
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Trans-septal Puncture
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Grasping →Imaging: LVOT
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↓ 3D TEE ↓
↓ 3D TEE ↓
Flail Gap and Width
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Coaptation Length
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Large Atrial Shunt→ ASD Occluder Placed