Percutaneous Mitral Valve Edge-to-Edge Repair With Simultaneous Biatrial Intracardiac Echocardiography
2016; Lippincott Williams & Wilkins; Volume: 133; Issue: 15 Linguagem: Inglês
10.1161/circulationaha.115.020923
ISSN1524-4539
AutoresJohannes Patzelt, Peter Seizer, Ying Ying Zhang, Tobias Walker, Jüergen Schreieck, Meinrad Gawaz, Harald F. Langer,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 133, No. 15Percutaneous Mitral Valve Edge-to-Edge Repair With Simultaneous Biatrial Intracardiac Echocardiography Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBPercutaneous Mitral Valve Edge-to-Edge Repair With Simultaneous Biatrial Intracardiac EchocardiographyFirst-in-Human Experience Johannes Patzelt, MD, Peter Seizer, MD, Ying Ying Zhang, MD, Tobias Walker, MD, Juergen Schreieck, MD, Meinrad Gawaz, MD and Harald F. Langer, MD Johannes PatzeltJohannes Patzelt From University Hospital, Department of Cardiology and Cardiovascular Medicine(J.P., P.S., Y.Y.Z., J.S., M.G., H.F.L.) and Department of Cardiovascular Surgery (T.W.), Eberhard Karls University Tuebingen, Germany. , Peter SeizerPeter Seizer From University Hospital, Department of Cardiology and Cardiovascular Medicine(J.P., P.S., Y.Y.Z., J.S., M.G., H.F.L.) and Department of Cardiovascular Surgery (T.W.), Eberhard Karls University Tuebingen, Germany. , Ying Ying ZhangYing Ying Zhang From University Hospital, Department of Cardiology and Cardiovascular Medicine(J.P., P.S., Y.Y.Z., J.S., M.G., H.F.L.) and Department of Cardiovascular Surgery (T.W.), Eberhard Karls University Tuebingen, Germany. , Tobias WalkerTobias Walker From University Hospital, Department of Cardiology and Cardiovascular Medicine(J.P., P.S., Y.Y.Z., J.S., M.G., H.F.L.) and Department of Cardiovascular Surgery (T.W.), Eberhard Karls University Tuebingen, Germany. , Juergen SchreieckJuergen Schreieck From University Hospital, Department of Cardiology and Cardiovascular Medicine(J.P., P.S., Y.Y.Z., J.S., M.G., H.F.L.) and Department of Cardiovascular Surgery (T.W.), Eberhard Karls University Tuebingen, Germany. , Meinrad GawazMeinrad Gawaz From University Hospital, Department of Cardiology and Cardiovascular Medicine(J.P., P.S., Y.Y.Z., J.S., M.G., H.F.L.) and Department of Cardiovascular Surgery (T.W.), Eberhard Karls University Tuebingen, Germany. and Harald F. LangerHarald F. Langer From University Hospital, Department of Cardiology and Cardiovascular Medicine(J.P., P.S., Y.Y.Z., J.S., M.G., H.F.L.) and Department of Cardiovascular Surgery (T.W.), Eberhard Karls University Tuebingen, Germany. Originally published12 Apr 2016https://doi.org/10.1161/CIRCULATIONAHA.115.020923Circulation. 2016;133:1517–1519Recently, we described a percutaneous mitral valve edge-to-edge repair (PMVR) procedure in a patient using both transesophageal echocardiography (TOE) and intracardiac echocardiography (ICE).1 In that patient, however, central steps of PMVR were guided primarily by TOE. Advantages of intracardiac echocardiography are avoidance of TOE and thus general anesthesia. The procedure can be performed in a conscious patient. Accordingly, the need for catecholamines, the risk of hypotension, prolonged periods of weaning from mechanical ventilation, and postinterventional delirium are reduced. Although in theory the use of left atrial ICE is sufficient to guide PMVR, ICE has not been used as the only imaging modality to guide PMVR because of disadvantages such as the lack of 3-dimensional (3D) vision with X-plane views and particularly the lack of experience using ICE for PMVR. Here, we report a PMVR procedure in a patient with functional mitral regurgitation (MR) using ICE because TOE guidance was not possible.CaseA 78-year-old patient presented with decompensated heart failure with MR grade IV (Figure, A and B). He had a history of repeated hospitalizations for heart failure caused by ischemic cardiomyopathy with severely reduced left ventricular function. An internal cardioverter-defibrillator had been implanted because he had repeated ventricular arrhythmias. As a result of severe comorbidities, a decision for PMVR was made by our interdisciplinary heart team. TOE was not possible (even with endoscopic guidance) because of the patient's anatomy, so we decided to perform the procedure using ICE. Because orthogonal 2-dimesional views of the mitral valve are required for PMVR, 2 ICE probes were used. First, an ICE probe (ViewFlex Plus ICE Catheter, St. Jude Medical) was advanced into the right atrium (Figure, C). After the distance from the planned puncture site to the valve was measured (Figure, D), an Amplatz Super Stiff guidewire (Boston Scientific) was placed into the upper left pulmonary vein (Figure, E). Then, the dilator and guide catheter were advanced into the left atrium with ICE guidance (Figure, F and G). Subsequently, a second ICE catheter was placed via a 10F transseptal sheath (bent 45°; St. Jude Medical) into the left atrium (Figure, H and I). With the use of conventional maneuvers, the clip was positioned over the mitral valve plane and carefully advanced through the valve (Figure, J and K). After adjustment of clip alignment, a grasp was performed, and the clip was closed to 30° (Figure, L–O). After determining whether we caught enough valve material for a sufficient grasp and whether we reduced MR, the clip was fully closed (Figure, O–Q). Then, the clip was deployed (Figure, R and Movie I in the online-only Data Supplement documenting all ICE sequences), and we observed a reduction of MR to grade I to II as confirmed by transthoracic echocardiography (Figure, S and T).DiscussionPMVR with the MitraClip system (Abbott Vascular) is an innovative method providing inoperable patients with a novel therapy option.2 However, there are cases in which PMVR is not possible for anatomic reasons (ie, patients beyond the Everest criteria) or contraindications for TOE. Here, we documented, for the first time to the best of our knowledge, that under given circumstances a PMVR procedure can be carried out without TOE guidance. In other settings, ICE is well established and used in everyday clinical practice. An advantage of ICE is excellent resolution because the probe is in close proximity to the object of interest without other structures affecting the view.3 In addition, no sedation is needed for ICE, minimizing the risk of hypotensive periods or drops in oxygen saturation. Disadvantages of ICE are the need for an additional puncture site in the femoral region with an additional 10F sheath and the additional transseptal puncture for left atrial access. Although there are first reports of 3D ICE during other procedures such as atrial fibrillation ablation,4 3D ICE is not routinely applied, and the ICE probes in use are generally 2-dimensional probes. In our case, we introduced two 2-dimensional ICE catheters to adjust for 2 orthogonal planes. The right atrial ICE provided a view resembling the intercommissural TOE view, and the grasping maneuver could be readily visualized by left atrial ICE.Future effort should focus on technical improvements such as 3D imaging and X-plane function to provide accuracy for clip positioning, improved color-flow mapping capabilities, and implementation of continuous-wave Doppler to screen for stenosis after clip deployment. Experience and further technical developments with 3D ICE in PMVR are needed to further advance the procedure and to make it accessible for patients with MR who are not eligible for conventional surgery.Download figureDownload PowerPointFigure. Images of intracardiac echocardiography (ICE), fluoroscopy, and transthoracic echocardiography (TTE) during percutaneous edge-to-edge mitral valve repair (see also Movie I in the online-only Data Supplement). A and B, TTE revealed functional mitral regurgitation (MR) grade IV (A, apical 4-chamber view; B, apical 2-chamber view). C, Fluoroscopic anterior-posterior view of the right atrial ICE probe. D, Visualization and measurement of the distance from the transseptal puncture to the mitral valve plane using the right atrial ICE probe (→ indicates septal tenting; * indicates an artifact). E, Fluoroscopic anterior-posterior view showing right atrial ICE and a stiff wire in the left upper pulmonary vein. F and G, View provided by the right atrial ICE showing the dilator (>) and the guide catheter (*) crossing the interatrial septum. H, Fluoroscopic anterior-posterior view showing right and left atrial ICE (→) and the guide catheter crossing the interatrial septum (*). I through L, Views provided by right atrial ICE. In I, > indicates the left atrial ICE probe. J, The clip is advanced into the left atrium and (K) positioned above the mitral annular plane. L, The clip (*) below the annular plane depicted in an "intercommissural-like" ICE view, documenting a central position. M, View provided by the left atrial ICE verifying good adaption of the anterior and posterior leaflet to the extended clip arms (→) in the central anterior-posterior position. N and O, The clip was partially closed for assessment of leaflet insertion by the left atrial ICE. P, Left atrial ICE view of the fully closed clip. Q, Residual MR after clip deployment as provided by the right atrial ICE. R, Fluoroscopic anterior-posterior view of the deployed clip. S and T, Residual MR grade I to II in TTE apical 4- and 2-chamber views.Sources of FundingThis study was supported by grants from the German Research Foundation (KFO 274) and the German Heart Foundation.DisclosuresDr Schreieck has received speaker fees from Medtronic and St. Jude Medical. Dr Langer was reimbursed by Abbott Vascular for training courses in the percutaneous mitral valve repair procedure. The other authors report no conflicts.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.020923/-/DC1.Correspondence to Harald F. Langer, MD, Department of Cardiology and Cardiovascular Medicine, Eberhard Karls University Tuebingen, Otfried-Mueller-Straße 10, 72076 Tuebingen, Germany. E-mail [email protected]References1. Henning A, Mueller II, Mueller K, Zuern C, Walker T, Gawaz M, Schreieck J, Langer HF. Percutaneous edge-to-edge mitral valve repair escorted by left atrial intracardiac echocardiography (ICE).Circulation. 2014; 130:e173–e174. doi: 10.1161/CIRCULATIONAHA.114.012504.LinkGoogle Scholar2. Feldman T, Foster E, Glower DD, Glower DG, Kar S, Rinaldi MJ, Fail PS, Smalling RW, Siegel R, Rose GA, Engeron E, Loghin C, Trento A, Skipper ER, Fudge T, Letsou GV, Massaro JM, Mauri L; EVEREST II Investigators. Percutaneous repair or surgery for mitral regurgitation.N Engl J Med. 2011; 364:1395–1406. doi: 10.1056/NEJMoa1009355.CrossrefMedlineGoogle Scholar3. Bartel T, Müller S, Biviano A, Hahn RT. Why is intracardiac echocardiography helpful? Benefits, costs, and how to learn.Eur Heart J. 2014; 35:69–76. doi: 10.1093/eurheartj/eht411.CrossrefMedlineGoogle Scholar4. Brysiewicz N, Mitiku T, Haleem K, Bhatt P, Al-Shaaraoui M, Clancy JF, Marieb MA, Sugeng L, Akar JG. 3D real-time intracardiac echocardiographic visualization of atrial structures relevant to atrial fibrillation ablation.JACC Cardiovasc Imaging. 2014; 7:97–100. doi: 10.1016/j.jcmg.2013.09.018.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Gheorghe L, Mobasseri S, Agricola E, Wang D, Milla F, Swaans M, Pandis D, Adams D, Yadav P, Sievert H, Ailawadi G and Sorajja P (2021) Imaging for Native Mitral Valve Surgical and Transcatheter Interventions, JACC: Cardiovascular Imaging, 10.1016/j.jcmg.2020.11.021, 14:1, (112-127), Online publication date: 1-Jan-2021. Marcoff L and Gillam L (2020) Role of the Imager in Transcatheter Mitral Valve Repair, Current Cardiology Reports, 10.1007/s11886-020-01362-6, 22:10, Online publication date: 1-Oct-2020. Patzelt J, Zhang Y, Magunia H, Ulrich M, Jorbenadze R, Droppa M, Zhang W, Lausberg H, Walker T, Rosenberger P, Seizer P, Gawaz M and Langer H (2017) Improved mitral valve coaptation and reduced mitral valve annular size after percutaneous mitral valve repair (PMVR) using the MitraClip system, European Heart Journal - Cardiovascular Imaging, 10.1093/ehjci/jex173, 19:7, (785-791), Online publication date: 1-Jul-2018. Jorbenadze R, Krüger T, Walker T, Schreieck J, Seizer P, Schlensak C and Langer H (2018) Percutaneous Edge-to-Edge Mitral Valve Repair (PMVR) in a Patient with Barlow's Disease, an Implanted Atrial Septal Defect (ASD) Occluder Device, and a Left Ventricular Assist Device (LVAD), Structural Heart, 10.1080/24748706.2018.1456706, 2:5, (469-470), Online publication date: 1-Sep-2018. Wunderlich N, Beigel R, Ho S, Nietlispach F, Cheng R, Agricola E and Siegel R (2018) Imaging for Mitral Interventions, JACC: Cardiovascular Imaging, 10.1016/j.jcmg.2018.02.024, 11:6, (872-901), Online publication date: 1-Jun-2018. Patzelt J, Schreieck J, Camus E, Gawaz M, Seizer P and Langer H (2017) Percutaneous Mitral Valve Edge-to-Edge Repair Using Volume Intracardiac Echocardiography—First in Human Experience, CASE, 10.1016/j.case.2017.01.006, 1:1, (41-43), Online publication date: 1-Feb-2017. Basman C, Parmar Y and Kronzon I (2017) Intracardiac Echocardiography for Structural Heart and Electrophysiological Interventions, Current Cardiology Reports, 10.1007/s11886-017-0902-6, 19:10, Online publication date: 1-Oct-2017. Patzelt J, Ulrich M, Becker A, Müller K, Jorbenadze R, Droppa M, Zhang W, Mandel S, Habel L, Lausberg H, Pöss J, Geisler T, Borst O, Rosenberger P, Schlensak C, Gawaz M, Schreieck J, Seizer P, Langer H and Cheungpasitporn W (2018) Previous TAVR in patients undergoing percutaneous edge-to-edge mitral valve repair (PMVR) affects improvement of MR, PLOS ONE, 10.1371/journal.pone.0205930, 13:10, (e0205930) April 12, 2016Vol 133, Issue 15 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.020923PMID: 27067088 Originally publishedApril 12, 2016 PDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsEchocardiographyValvular Heart Disease
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