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Fig. 40.3 The four commercially available devices for transcatheter aortic valve treatment. (a) The self-expanding Evolut Pro device (Medtronic, Minneapolis, Minnesota). (b) The balloon-expandable

SAPIEN 3 (Edwards Lifesciences, California). (c) The self-expanding Portico (Abbott, Abbott Park, Illinois). (d) The self-expanding ACURATE neo2 (Boston Scientic, Marlborough, Massachusetts)

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Fig. 40.4 Final aortogram of a successfully implanted self-expanding Evolut Pro valve

aortic valve (supra-annular valve function), the operator must continue device deployment until blood pressure recovers. An indicator provides feedback to the operator that the capsule is close to the “no recapture point” (at approximately two-third deployed). At this point, the valve should be functionable and blood pressure restored. The imaging projection should be adjusted to align the valve inow and determine valve position using aortic root angiography. If the operator is satised with the valve position the valve is fully released. The detachment of frame paddles must be conrmed under uoroscopy (Fig.40.4).

Balloon-Expandable SAPIEN 3 (Edwards Lifesciences, California) (Fig.40.3b)

Device characteristics: The SAPIEN 3 (Edwards Lifesciences) valve is the fourth generation of the balloonexpandable SAPIEN device series. It is available in four sizes (20, 23, 26, and 29 mm). It consists of a cobaltchromium frame, three bovine pericardial tissue leaets, and a polyethylene terephthalate (PET) skirt at its inow portion and an outer PET sealing skirt to reduce PVR.The delivery system is advanced through a 14Fr (for 20, 23, 26 mm valves) and 16Fr (for 29-mm valve) expandable sheath.

Implantation technique: The current SAPIEN 3 (S3) system requires valve alignment and positioning on the balloon. According to the manufacturer, this should be performed in the descending aorta. The valve system is then advanced across the aortic arch, utilizing the retroex system. The valve is advanced across the aortic valve and positioned at the annulus based on the middle marker on the valve. Once positioning is conrmed, the valve is deployed under rapid

K. Kalogeras and M. Vavuranakis

ventricular pacing at approximately 180bpm. The balloon ination should be held for 3–5s and subsequently deated before rapid pacing is stopped. Finally, the balloon catheter is withdrawn to the ascending aorta.

Self-expanding Portico (Abbott, Abbott Park, Illinois) (Fig.40.3c)

Device characteristics: The Portico valve is composed of a self-expanding stent, bovine leaets, and a porcine pericardial sealing cuff. It is characterized by the large cell area and annular function of its leaets, permitting the catheter engagement of the coronary ostia post-procedurally. The 23 and 25mm valves are loaded onto an 18Fr delivery system, whereas the 27 and 29mm valves are loaded onto a 19F delivery system. The Portico valve can be implanted transfemorally and, when implanted with the SoloPath introducer (St. Jude Medical, Inc.), has a low 13.5Fr insertion prole.

Implantation technique: The device is initially advanced across the aortic valve, and the delivery system is positioned so that the inner shaft marker band is aligned with the annular plane. Unsheathing is performed by turning the deployment wheel occasionally under controlled pacing (90–120bpm). There is a clicking sound when the delivery system has reached the partial deployment lock. The deployment mechanism will not re-engage until the deployment lock button is depressed. The imaging projection should now be adjusted to align the valve inow and then conrm the appropriate position using aortic root angiography. Once conrmed, after pressing the deployment lock button, the deployment is completed by turning the deployment wheel until the valve capsule is fully retracted. The detachment of retainer tabs must be conrmed under uoroscopy before the system is withdrawn.

Self-expanding ACURATE Neo2 (Boston Scientic, Marlborough, Massachusetts) (Fig.40.3d)

Device characteristics: The ACURATE neo device is a second- generation porcine pericardium valve sewn onto a self-expanding nitinol stent. It is covered by a porcine pericardium skirt. The device includes three stabilization arches aiming for axial alignment in the aortic annulus, a top crown for capping the aortic annulus, and a bottom that is open to the full distribution of the native valve. The device can be implanted through either the transapical (28Fr) or the transfemoral (18 Fr) routes using a two-step deployment. The ACURATE neo comes in three different sizes: small (21– 23mm aortic annulus), medium (23–25mm aortic annulus), and large (25–27mm aortic annulus).

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Implantation technique: ACURATE neo has a unique deployment system. Due to the lower radial force, balloon pre-dilatation is recommended to facilitate device expansion. Once the device has crossed the aortic valve, it should be carefully positioned as indicated by the radiopaque marker at the annular plane. Deployment can be performed in a twostep manner. The rst step includes turning the rotating knob until full stop. This step should be done rather slowly in order to avoid inappropriate movement of the device. Then, the stabilization arms are fully deployed, and the upper crown is partly deployed. Once the position of the valve is veried with aortic root angiography, the second step is initiated by removing the safety knob. Subsequently, the second rotating knob is turned until full stop with full deployment of the device. Finally, the detachment of the frame paddles must be conrmed under uoroscopy.

14. After valve deployment, a pigtail catheter is introduced

into the LV in order to measure simultaneous pressures across the prosthetic valve. Subsequently, aortic root angiography is performed to assess the appropriate position of the device and the presence/severity of paravalvular regurgitation (PVR).

15. Post-dilatation may be performed to achieve optimal

device expansion and reduce PVR.The size of the balloon is typically the same as the derived annulus diameter measured in TAVI CT.

16. Access site closure. The TAVI sheath is carefully with-

drawn into the ipsilateral iliac artery. The contralateral femoral access site may be used for “cross-over” to the main access side using an IMA diagnostic or pigtail catheter. This catheter will facilitate conrmation of the nal angiographic result after removal of the TAVI sheath. The pre-closure sutures are tightened after sheath removal with a guidewire 0.035″ usually still in place. The “cross-over” catheter can be used for bailout balloon angioplasty or covered stent implantation in the case of major vascular complication. Manual compression may be required if minor bleeding persists [26].

17. In cases of pre-existing permanent pacemakers, the tem-

porary pacing wire is removed. Otherwise, it should be safely secured until its removal is considered safe for the patient.

18. Bedside TEE is performed at the end of the procedure,

either in the cath lab or as soon as the patient arrives in the cardiac intensive care unit. Valve function is assessed, and new pericardial effusion should be excluded. The cardiac monitor should also be assessed for evidence of new conduction disturbances.

Alternative Access Sites Transsubclavian Access

Transsubclavian access is the most commonly used alternative access. Transsubclavian access is typically performed via surgical cut-down. Usually it is performed from the left side due to the more favorable alignment of the device with the native valve. The presence of the left internal mammary artery graft in patients with coronary artery bypass surgery is considered a relative contra-indication [27, 28].

Transapical Access

Transapical access is performed via a left anterolateral intercostal incision followed by needle puncture of the apex under general anesthesia. A sheath is inserted, and the device is deployed similarly to the transfemoral approach. This access is typically used for the Edwards SAPIEN platform [27].

Transaortic Access

Transaortic access is performed through the ascending aorta via a right anterior mini-thoracotomy in the second intercostal space. It is tried to avoid areas of calcication. The valve is deployed in the same way as via the transfemoral approach [27, 29].

Transcarotid Access

Transcarotid access is performed percutaneously under local anesthesia with cerebral oximetry monitoring. The size and quality of the vessel are necessary determinants for efcacy and safety, as well as an anatomically complete Circle of Willis [27, 30].

Transcaval Access

This is a more complex approach, requiring the insertion of the delivery sheath from the inferior vena cava into the abdominal aorta for valve delivery. Access is performed in experienced centers, with limited patients requiring alternative access.

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Procedural Complications

Operators have to be prepared for complications and emergencies when performing TAVI. Common complications during and after TAVR are as follows.

Paravalvular regurgitation (PVR): PVR is usually estimated post-procedurally by aortic root angiography and/or transthoracic echocardiography. If considered signicant, various measures according to the underlying mechanism can be applied. If the leak is due to under-expansion of the device, post-dilatation should be performed to achieve optimal expansion. In the case of malposition, a valve-in-valve procedure may be considered. Advances in the design of the current valves such as a circumferential outer sealing skirt and repositionable features (in some self-expanding devices) have remarkably reduced the risk of PVR. Self-expanding valves are considered to have higher PVR rates compared to balloon-expandable devices (3.4% vs. 0.8% for moderate/ severe PVR respectively). Although moderate or severe PVR has been consistently associated with increased mortality, there is conicting data on the adverse effect of mild PVR [10, 31, 32].

Coronary artery obstruction: Coronary artery obstruction is a rare (<1%) but life- threatening complication caused by native leaets or device material overlapping the coronary ostia. More commonly, the left main coronary artery is involved in obstruction. Low coronary height (<10mm), narrow sinus of Valsalva, as well as heavily calcied aortic leaflets are considered high-risk anatomic features. If patients are considered at high risk, preventative strategies such as coronary protection with a coronary stent in place may be considered. Acute coronary artery obstruction typically causes rapidly worsening hypotension with electrocardiographic changes. Immediate angiographic assessment should be performed to identify the affected lesion [33, 34].

Annular rupture: Annular rupture is a rare (<1%) but devastating complication that may occur after balloonexpandable valve implantation or aggressive pre/post-dilation of a severely calcied valve. The treatment approach includes surgical repair/reconstruction and pericardial drainage [35].

Device embolization: Valve embolization occurs in approximately 1%. Valve dislocations are either toward the aorta or into the LV cavity. It can occur immediately, during, or after THV implantation, or as a late device migration. Bailout measures include repositioning attempts using snares, multiple valve implantation, or conversion to surgery [36].

Vascular complications: The incidence of vascular complications has decreased over time (2–4% in the recent lowrisk trials) due to the development of smaller and more exible delivery systems. Vascular complications typically include dissection, stenosis, perforation, and pseudoaneu-

rysm or aneurysm. Usually it is caused due to closure device failure. Vascular complications can be treated percutaneously using bailout balloon angioplasty or covered stent implantation via the cross-over catheter. Surgical repair is typically reserved for extensive dissection or bleeding or challenging anatomy [37, 38].

Atrioventricular (AV) conduction disturbance: AV conduction impairment, including advanced heart block and new LBBB, is a common adverse event and remains a limitation of TAVI. It is higher with self-expanding valves compared to balloon- expandable devices (17.4% vs. 6.5% respectively in recent low-risk patient trials). Pre-existing right bundle branch block, non-coronary cusp device landing zone calcication, and deep implantation of the valve have been identied as independent predictors of new conduction disturbances. Although AV conduction impairment typically occurs within 24h, sometimes it can be developed later than 48 h after implantation. Therefore, temporary pacing wire placed during the procedure should be kept in place for the rst 24h, while monitoring by telemetry should be continued after the procedure, and a potential risk assessment of delayed conduction disturbances should be made before discharge [39, 40].

Stroke: Stroke remains one of the most feared complications of TAVI associated with considerable morbidity and mortality. Stroke related to TAVI most frequently occurs during or within 24–48h after the procedure. TAVI is reported to be associated with a 19% lower risk of stroke throughout 2years compared with surgical replacement. Optimal anticoagulation during the procedure is essential for the prevention of stroke. Cerebral embolic protection devices have been developed and used for the prevention of cerebrovascular events peri-procedurally [41, 42].

Antithrombotic Management

For patients undergoing TAVI life-long single antiplatelet therapy (SAPT) with low- dose aspirin (75–100mg daily) is suggested [16, 43]. If aspirin is contraindicated, clopidogrel or another P2Y12 inhibitor may be prescribed as an alternative. Until recently, the use of dual-antiplatelet therapy (DAPT) for 3–6 months followed by life-long SAPT has been the default strategy. However, recent trials have shown that SAPT is superior in terms of the composite endpoint of bleeding events and noninferior in terms of thromboembolic events compared to DAPT [44]. If there is an established indication for DAPT, the antithrombotic management should follow the recommendations for the indication. For patients with an established indication for oral anticoagulation (OAC), OAC should be continued after TAVI [45]. However, whether these patients should be treated with DOACs or VKA remains a subject of debate [46, 47].

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Durability Data

TAVI is an increasingly used modality which is gradually expanding to younger and lower-risk population with longer life expectancy. Favorable data regarding the durability of transcatheter implanted valves have been reported from the randomized clinical trials and large-scale real-world registries but are limited up to 8years [48, 49].

The rates of structural valve deterioration and bioprosthetic valve failure between 5 and 8years after TAVI ranged from 3.8 to 18.6% and 2.5 to 7.5%, depending on the denitions, the timing, and the type of valve used. When compared to surgical valves, the durability of the transcatheter devices was largely comparable up to 6 years [50]. However, it should be underlined that bioprosthetic valve deterioration mostly occurs >8–10years after SAVR.Thus, longer-term follow-up data are required [51–53] (Table40.1).

Table 40.1 Suggested Endovascular Toolkit for the transcatheter treatment of aortic stenosis. These are only a few suggested options based on the author’s experience and can cover the vast majority of cases

Manufacturer Size/length

Wires

Any standard access wire Straight-tip wire Any

Exchange-length wire Any

Amplatz super stiff wire Boston Scientic

Pre-shaped curve stiff wire

Sheaths

Any standard access femoral sheath Large-caliper femoral sheath introducer

Catheters

Pigtail Any 6Fr/100cm Internal mammary artery (IMA) Amplatz left 1–2 Any 6Fr/100cm

Balloons

High-pressure, semi- compliant/ compliant balloon Peripheral vessels angioplasty balloon Temporary pacing wire Any Suture-mediated closure system

Transcatheter aortic valve system

Evolut R/Pro (self-expanding) Portico (self-expanding) Abbott 23–25–27–29mm ACURATE-Neo 2 (self-expanding) SAPIEN 3/ultra (balloon-expandable)

Any

Any 6Fr/11cm

Cook Medical 14–18Fr/30–45cm

Any 6Fr/100cm

Bard Medical/ Balt extrusion

Any 5–10mm/35mm

Perclose ProGlide/Abbott

Medtronic 23–26–29–34mm

Boston Scientic S (23mm)–M

Edwards 20–23–26–29mm

0.035″

18–28mm/40mm

(25mm)–L (27mm)

Case Presentation

Continued from page 441

Following an intravenous dose of amoxicillin/clavulanic the patient was transferred to the cath lab, and under conscious sedation an arterial (6Fr) and venous (6Fr) access were gained. A temporary pacing wire was placed in the right ventricle. Through the 6Fr arterial sheath and an internal mammary (IMA) catheter, a guided puncture of the contralateral common femoral artery was conducted. Two ProGlide vascular closure devices were deployed, and over a Super Stiff 0.035″ wire, a 14Fr long sheath was introduced.

Sequential aortograms were conducted through a 6 Fr pigtail catheter identifying the cusp overlap view. Utilizing a 6Fr Amplatz left 1 diagnostic catheter, a straight tip 0.035″ wire crossed the stenotic valve, and the catheter was advanced in the LV.Using a long exchange wire, a 6Fr pigtail catheter was advanced in LV, and a peak-to-peak gradient measurement was gained through the two pigtails (in aortic root and LV). The LV pigtail catheter was exchanged for a long preshaped Super Stiff 0.035″ wire (Conda). Due to extreme calcication of the aortic leaets, a pre-dilatation of the aortic valve was made under rapid (180bpm) pacing with a 20 × 40 mm balloon without hemodynamic deterioration. Following this, the 14Fr sheath was removed, and a 29mm Evolut-Pro self-expanding device was gradually advanced over its in-line delivery sheath across the descending aorta, the aortic arch, and nally the aortic valve. Valve deployment, guided by aortograms, was initiated by gradual anticlockwise turning of the device delivery knob until pressure dropped (half way opening). Device deployment was then accelerated until reaching the “no recapture point,” and a nal aortogram was made. Device’s appropriate implantation depth and coronaries’ adequate perfusion were conrmed before nal release of the valve.

The delivery system is then removed from the body and replaced by the 14Fr sheath. The newly implanted valve is crossed with a pigtail catheter, and the new peak-to-peak gradient is recorded conrming an optimal hemodynamic result. A nal aortogram is made to exclude any more than mild paravalvular regurgitation. Finally, the 14 Fr sheath is removed, and the two ProGlide devices’ sutures seal the puncture site of the main access artery. A contralateral contrast infusion through an IMA or pigtail catheter conrmed the effective sealing of the access site. Since the patient developed a mild QRS prolongation after valve implantation, the temporary pacing wire was left in place for at least 24h until any severe conduction disturbances were excluded.

The patient was transferred to the coronary intensive care unit. The pacing wire was removed the next day, and he was mobilized without any problems. He was placed on single antiplatelet therapy and discharged 3days later. At 1-month follow-up he described improvement of his symptoms, while transthoracic echocardiogram conrmed a well-functioning prosthetic aortic valve.

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39. Scarsini R, De Maria GL, Joseph J, Fan L, Cahill TJ, Kotronias RA, et al. Impact of complications during transfemoral transcatheter aortic valve replacement: how can they be avoided and managed? J Am Heart Assoc. 2019;8(18):e013801.

40. Maeno Y, Abramowitz Y, Kawamori H, Kazuno Y, Kubo S, Takahashi N, etal. A highly predictive risk model for pacemaker implantation after TAVR.JACC Cardiovasc Imaging. 2017;10(10 Pt A):1139–47.

41. Siontis GCM, Overtchouk P, Cahill TJ, Modine T, Prendergast B, Praz F, et al. Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis. Eur Heart J. 2019;40(38):3143–53.

42. Vlastra W, Jimenez-Quevedo P, Tchetche D, Chandrasekhar J, de Brito FS Jr, Barbanti M, etal. Predictors, incidence, and outcomes of patients undergoing transfemoral transcatheter aortic valve implantation complicated by stroke. Circ Cardiovasc Interv. 2019;12(3):e007546.

43. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, etal. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines. Circulation. 2021;143(5):e35–71.

44. Brouwer J, Nijenhuis VJ, Delewi R, Hermanides RS, Holvoet W, Dubois CLF, et al. Aspirin with or without clopidogrel after transcatheter aortic-valve implantation. N Engl J Med. 2020;383(15):1447–57.

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50. Sondergaard L, Ihlemann N, Capodanno D, Jorgensen TH, Nissen H, Kjeldsen BJ, etal. Durability of transcatheter and surgical bioprosthetic aortic valves in patients at lower surgical risk. J Am Coll Cardiol. 2019;73(5):546–53.

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Transcatheter Mitral Valve Repair

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RomainGallet andEmmanuelTeiger

Case Presentation

An 83-year-old woman was referred to the hospital by her cardiologist for mitral regurgitation- related heart failure.

She had been complaining of dyspnea for a week. This dyspnea had been progressively increasing, leading to the necessity of sleeping in an armchair.

Her previous medical history included chronic kidney disease (creatinine clearance 45mL/min) and a right carotid endarterectomy. The transthoracic echocardiography performed by her cardiologist had revealed severe mitral regurgitation (MR) as a result of chordal rupture on the anterior leaet at the level of the A2 segment. The width of the prolapse was 8 mm. This mitral regurgitation was associated with an increase in systolic pulmonary pressure to 60mm Hg. Left ventricle was hyperkinetic and left atrium was not dilated, suggesting a recent MR.

Given the high/prohibitive surgical risk (Euroscore 2

14.28%), a percutaneous treatment of this recent MR was discussed.

Continued on page 461

Background

Mitral regurgitation is the second most common valvulopathy, and degenerative mitral valve disease affects approximately 18 million people worldwide [1, 2]. It can be related to a disease of the mitral valve itself (primary or organic MR) or to a disease of the left ventricle and/or the left atrium leading to annulus enlargement causing MR (secondary or functional MR). The occurrence of severe MR is associated with increased morbidity (including hospitalization for pulmonary edema and atrial brillation) and mortality. For primary MR the standard of care remains the surgical correction of the MR through repair or replacement of the damaged valve

R. Gallet (*) · E. Teiger Cardiology Department, Hôpitaux Universitaires Henri Mondor, Créteil, France e-mail: romain.gallet@aphp.fr; emmanuel.teiger@aphp.fr

[3]. However, surgery may be high risk or even not an option in elderly, comorbid, and/or frail patients [4]. Therefore, other strategies have been (and are currently being) developed. Among those strategies, edge-to-edge percutaneous repair has been the most used and studied and is currently the only recommended option. This technic has been inspired by Aleri stitch [5, 6] and has been proven effective in both primary and secondary MR [7–10].

Indications forIntervention

The indications for intervention in primary mitral regurgitation have been dened in the guidelines of the European Society of Cardiology [3]. It includes high-grade MR in symptomatic patients who are operable without high risk, asymptomatic patients with LV dysfunction (LVESD ≥40mm and/or LVEF ≤60%), asymptomatic patients with atrial brillation secondary to mitral regurgitation, or pulmonary hypertension (SPAP at rest >50 mmHg), and asymptomatic patients with left atrium enlargement due to the MR (volume index ≥60mL/m [2] or diameter ≥55 mm) and a likely durable repair. The gold standard for treatment currently remains surgical repair or replacement.

Edge-to-edge repair should only be considered for symptomatic patients who fulll the echocardiographic criteria of eligibility with high or prohibitive surgical risk assessed by surgical risk scores or frailty. Regarding secondary mitral regurgitation, the data are more controversial since two randomized studies comparing optimal medical therapy to edge-to-edge percutaneous repair came out with opposite results [10, 11]. While the Mitra-FR study was negative, the COAPT trial showed an impressive decrease in mortality and hospitalization with the MitraClip therapy as compared to optimal medical therapy. The patients enrolled in those studies were not similar and therefore the guidelines for interventions in secondary mitral regurgitations have taken into account these differences [12–15]. Thus, percutaneous edgeto- edge mitral repair is mainly recommended in patients with symptomatic MR with an EROA ≥30mm2, an LV end-

447

448

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R. Gallet and E. Teiger

systolic diameter≤70mm a LVEF of 20–50%, and a favorable anatomy3. Except in rare selected cases it should not be performed in patients with a cause of heart failure other that dilated cardiomyopathy (restrictive, hypertrophic, inltrative), in patients with severe pulmonary hypertension (>70 mmHg) or right ventricle failure, or in patients with hemodynamic instability or severe disability or frailty.

Preoperative Preparation

Timing ofIntervention

All interventions should be discussed among the heart team to conrm patient candidacy for percutaneous mitral valve edge-to-edge repair and anatomic feasibility of clip placement. In case of secondary MR or well-tolerated primary MR, intervention is not urgent and should be performed after thorough pre-procedural planning. The timing for intervention is usually a few weeks after evaluation and long delays should be avoided to prevent the (further) impairment of LV function and subsequently RV function in response to the MR.

In case of acute symptomatic primary MR (usually related to chordae rupture) or ischemic MR, intervention should be performed within a few days because of the risk of massive pulmonary edema and sudden cardiac death.

Imaging

Table 41.1 Echocardiographic criteria for high-grade MR

Primary MR Secondary MR

Qualitative

Mitral valve morphology

Color ow jet area Flow convergence Continuous wave Doppler jet

Semiquantitative

Vena contracta width (mm) Pulmonary vein ow Mitral inow E-wave dominant (>1.2m/S) TVI Mitral/TVI aortic ratio

Quantitative

EROA (mm2)

Regurgitant volume (mL/ beat)

Regurgitant fraction (%)

Structural

Left ventricle Dilated Left atrium Dilated

Adapated from Eur Heart J. 2022 Feb 12;43(7):561–632

Large prolapse or ail leaet, ruptured papillary muscle, severe retraction, large perforation Large central jet (>50% of LA) or eccentric wall impinging jet of variable size Large, holosystolic

Holosystolic/dense/triangular

≥7 (≥8mm for biplane)

Systolic ow reversal

>1.4

≥40mm² ≥40mm² (may be

≥60mL ≥60mL (may be 45

≥50%

Severe tenting, poor leaet coaptation. Usually normal leaets

≥30mm² if elliptical ROA)

≥ mL if low ow conditions)

Transthoracic andTransesophageal Echocardiography

Transthoracic and multi-plan transesophageal echocardiography (TEE) are the cornerstone of the evaluation of MR on one side and of the assessment of the feasibility of transcatheter repair on the other side [8].

Regarding the grading of MR, the different techniques for quantication and grading are detailed in the guidelines of the European Society of Cardiology. Briey, quantication should include, among all vena contracta, TVI ratio, effective regurgitant orice area as well as regurgitant volume or fraction, pulmonary vein ow measurement, and LV morphology assessment [3]. Only high-grade symptomatic MR dened by the criteria in Table41.1 is eligible for percutaneous repair.

Regarding feasibility, the criteria for primary and secondary MR are summarized in Table41.2 [16]. In primary MR, a non-commissural ail with a gap below 10mm and a width below 15mm is usually favorable for edge-to-edge repair, while short leaets, calcied leaets, or commissural ails

are usually predictive of difcult or failed procedures and should be performed only by experienced operators.

Regarding secondary MR, besides the criterion for indication, the main criteria for feasibility are the length of the coaptation defect and the length of the leaet.

Additionally, TEE will evaluate the size of the left atrium and the morphology of the inter-atrial septum to evaluate the feasibility of trans-septal access and navigation into the left atrium.

Lastly, the left appendage will be visualized to rule out any thrombus that would temporarily contra-indicate the procedure.

Cardiac MRI

Cardiac MRI ideally with 4D-ow analysis is not mandatory in pre-procedural planning but may be useful in case of MR with difcult quantication, especially for MR with a very offset jet [17]. It can also provide a more accurate assessment of residual MR after MitraClip in difcult cases [18, 19].

41 Transcatheter Mitral Valve Repair

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449

Table 41.2 Echocardiographic criteria for feasability of MitraClip procedures

Optimal Challenging Complex – central A2/P2– Commissural (A1/P1, A3/

P3)

– No

calcication

– Mitral valve

area >4cm

– Posterior

leaet >10mm

– Tenting

height <10mm

– Normal

leaets and mobility

– Flail gap <

10 mm, ail width <15mm

Operator’s experience /volume of procedures in the centre increase

Adapted from Eur Heart J Cardiovasc Imaging 2020;21:1059–1067

– Severe calcication of

annulus, non in grasping zone

– 4cm2>MVA>3cm

– Posterior leaet 7–10mm – Rheumatic

– Tenting height >10mm – Carpentier

– Carpentier IIIB (leaet

restriction)

– Flail width >15mm

– Grasping zone

– MVA <3cm

– Posterior

with calcium

leaet <7mm, cleft

IIIB, multiple segments, Barlow

Table 41.3 Suggested endovascular toolkit for percutaneous edge-toedge mitral repair. These are only a few suggested options based on the author’s experience and can cover the vast majority of cases

Manufacturer Size/Length Wires Any standard access wire

Any 0.032″ wire 0.032″ Amplatzer superstiff Boston Scientic

Corporation Sheaths and dilators Any standard access sheath 5–10Fr/11cm Any dilators 18Fr–22Fr Catheters Transseptal catheter SL0 Or TorFlex transseptal catheter BRK transsptal needle Or NRG transseptal needle Or ProTrack Pigtail Wire MitraClip steerable guide catheter MitraClip and clip delivery system NT, XT, NTW or XTW Abbott Vascular closure Devices Perclose Proglides Abbott 8Fr

Abbott

Baylis

Abbott

Baylis

Abbott 24Fr–800mm

Abbott

0.035″

Endovascular Strategy andTechnique

Basic Endovascular Toolkit

• Standard access wires and sheaths including a short 6 or 8 Fr sheath

• Floppy and stiff 035″ guidewire

• A set of dilators, for example 12 Fr, 18 Fr, and 22 Fr

• Trans-septal kit including a 032″ guidewire, a trans-septal catheter, and a trans-septal needle (see below)

• An arterial line for pressure monitoring and blood draw for repeated ACT measurements

A list of suggested materials is summarized in Table41.3.

Transesophageal Echocardiography

Transesophageal echocardiographic guidance of the procedure with multi-planar and 3-dimensional acquisition is mandatory for transcatheter edge-to-edge repair (TEER) of MR. Indeed, echography will guide the whole procedure, from trans-septal puncture to clip positioning, leaet grasping, and clip release. The procedure will therefore require

very close communication between the echographist and the interventional cardiologist.

Trans-septal Kit

The trans-septal kit should include a trans-septal catheter, a trans-septal needle, and a dedicated guidewire. Another option which is particularly interesting in difcult transseptal crossing (thick or very oppy septum, unusual orientation) is the use of a system using radiofrequency [20, 21]. With such systems, the crossing of the septum relies on radiofrequency and not on the needle and may result in easier and safer trans-septal access.

Transcatheter Edge-to-Edge Repair Device

To date, two different devices are available for TEER of the mitral valve, the MitraClip and the Pascal [22]. The most widely studied and used device is the MitraClip device. The principle of the technique is to capture the anterior and posterior leaets of the mitral valve at the location of the MR to treat the prolapse in primary MR and to decrease coaptation defect and MR in secondary MR.Each leaet will be captured between a gripper and the arm of the clip. The clip will then be closed to bring the edges of the leaets closer.

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