1. Case Demonstration: MitraClip Edge-to–Edge Repair
James Hermiller, MD, FACC, FSCAI
St Vincent Hospital, Indianapolis, IN

2. James Hermiller, MD DISCLOSURES Consulting Fees
Abbott Vascular, Boston Scientific Corporation, St. Jude Medical
I intend to reference unlabeled/ unapproved uses of drugs or devices in my presentation.
I intend to reference date and guidelines for drug-eluting stents.

3. 73 year old man status post CABG on two occasions -- multiple co-morbidities including renal insufficiency – Cr 2.4, prior CVA, and LVD -- EF 30%
FC IV CHF with a 3 year history of recurrent hospital admissions (9 admissions) despite maximum medical therapy

4. Baseline Echo/TEE
4+ functional MR with teathering of posterior leaflet and malcoaptation -- MR jet localized within A2-P2

6. Eligibility:
Sufficient leaflet tissue available for mechanical coaptation
> 2mm “vertical” leaflet tissue available
Absence of severe LV dysfunction
Excluding LVID-s > 55mm or EF <25% (HRR: >60mm; <20%)
Ischemic or non-ischemic etiology
<2mm

7. Turned down by multiple surgical programs across country
Enrolled in ongoing REALISM continued access registry -- surgeon agreeing to backup surgically

8. Patient/valve selection TEE images Transseptal Puncture
Success
Patient/valve selection
TEE images
Transseptal Puncture

9. Ideal transseptal location
Echo Guided “two-dimensional” puncture
Through “Posterior” aspect of fossa
Through “Superior” portion of fossa
 Guide further away from plane of MV: “working space” (less needed for functional because of valve teathering into LV)
Echocardiography!
Pull back from SVC in Bi-caval view to membranous septum
Observe “tenting” in SAX view at base (A-P)
AND
In “4-Chamber” view (Working Space - > 3 CM)
Shape needle or BRK1 Broc. Needle

11. Mullins sheath won’t follow dilator – Inoue wire through dilator -- generally Mullins sheath will then follow dilator

12. Sheath won’t follow
Inoue dilator
Mullins sheath follows and exchange for super stiff Amplatz exchange wire looped in LA or positioned in pulmonary vein

13. MitraClip guide won’t cross septum despite Inoue dilator -- 6 mm x 4cm PTA balloon

14. Move clip delivery system in until it straddles guide

15. Torque Guide
Pull system in or out
Clip Delivery System
M/L Knob
on clip delivery
system
Guide

16. Torque Guide
Clockwise=Posterior
Counter Clockwise=Anterior

17. Torque Guide
Pull system in or out
Clip Delivery System
M/L Knob
on clip delivery
system
Guide

18. Torque Guide

19. Medial (M-Knob) deflection followed by posterior guide deflection until clip passes Coumadin ridge

20. Test trajectory (Too anterior – clock-wise/posterior guide torque)

21. Once trajectory (vector into valve) is acceptable, position clip optimally (generally split the regurgitant jet)
If clearly two clip case, may go a bit medial or lateral for the first clip
Iterative movements in long axis (A-P) and intercommissural (medial-laterial) views
A-P position – guide rotation
Medial Lateral – M/L deflection
If trajectory is acceptable, pull entire system too position more medially and push system in to position more laterally

22. A bit medial but excellent trajectory – entire systemg (guide too) moved in slightly

23. Next – cross valve – clip open to 180 degrees with cross (first clip)
Ensure that clip is perpendicular to line of coaptation (AP, intercommisural and gastric projections)

24. Cross valve and ensure clip is perpendicular
to line of coaptation
Long axis and transgastric SAX

25. Clip to 160 degrees and retract slowly until leaflets fall into clip
Drop grippers and tighten clip to 60 degrees and assess grasp

26. First grasp – MR moderate

27. Second and several subsequent grasps – Missed Posterior Leaflet

28. Final grasp – leaflet grasp stable

32. Follow Up
Discharge following day; currently feels well and has been out walking again
Functional Class I-II
No readmissions – Creatinine improved to 1.5 mg/dl
6 month echo – 1+ MR

33. Summary
MitraClip delivery has become systematic, and much easier and faster than early experience
Transseptal puncture location critical as is excellent TEE imaging
Promising therapy particularly for this subset of MR patients who are often high risk surgical candidates

36. Procedure steps Guide into LA Clip toward MV Clip across MV
Everted to pull back Leaflets grasped Clip closed

37. Clip closed Both leaflets grasped SAX double orifice