Percutaneous Mitral Valve Repair with MitraClip

Percutaneous Mitral Valve Repair with MitraClip

Mitral clip is a niche device to treat patients with severe mitral valve leak without open heart surgery. Our heart has four valves. These valves regulate blood flow through the heart. The mitral valve which is on the left side of the heart controls blood flow from the atrium to the ventricle. This valve has two leaflets that open and close within the heart ensuring that blood travels in only one direction.

Mitral regurgitation is leakage of blood backward to the left atrium through the mitral valve each time the left ventricle contracts. The heart’s mitral valve does not close tightly enough. This lets some of the blood in your heart flow backward or “regurgitate,” into your heart chamber. As a result, the heart must work harder to push blood through the body. Common symptoms caused by this increased workload include fatigue, shortness of breath, coughing, an irregular heartbeat and worsening heart failure. Mitral regurgitation is a progressive disease that can eventually impact your quality of life and make daily activities more difficult.

MitraClip is breakthrough innovative catheter-based technology that uses a small clip attached to the mitral valve to treat degenerative mitral regurgitation. MitraClip allows the mitral valve to close more completely, helping to restore normal blood flow through the heart. It’s a minimally invasive treatment option for patients with mitral regurgitation (valve leak) who are not good candidates for surgery.

Selection Process for MitraClip Therapy

The goal of treatment is to reduce the mitral regurgitation and improve overall quality of life. Medications may reduce the symptoms, but cannot fix the valve itself. The current treatment for severely leaking mitral valve is to perform repair or replacement of the mitral valve with open heart surgery. Open heart mitral valve surgery is an effective and well-proven way to treat the mitral regurgitation, but not all patients are suitable for open heart surgery. If a patient has other medical problems, open heart surgery can be too high risk.

In such cases, Mitral clip may be good option to treat the leaking valve without open heart surgery. First step is to check whether the patient is suitable for the mitral clip procedure; which will be decided by our team consisting of Cardiologists who are leaders in structural interventions along with the Cardiac Surgeon and Cardiac Anesthesiologist. Transthoracic Echocardiogram (TTE), is an important test to decide the suitability and specific measurements of the mitral valve. With these information, our MitraClip Heart team will discuss the case details, to make sure that the patient is getting the right procedure and would be benefited by this procedure. If a patient is not found suitable for the MitraClip procedure, it means that the patient will not be benefited from this procedure and may do better with open heart surgery or with current prescribed medications alone.

The MitraClip procedure is performed in the cathlab, by inserting a catheter through the groin. The catheter a long, flexible tube is inserted into a large vein in your groin (femoral vein) and guided to the heart. It is positioned using trans oesophageal echocardiogram and X-ray fluoroscopic images. Once the tip of the catheter has reached the heart, mitral valve is assessed with the transesophageal echocardiogram. The TEE aids in the correct placement of the MitraClip. Through the septal puncture – a tiny hole is made through the upper chambers (atria) of the heart, the catheter is inserted and guided to the left side, where the mitral valve is located. Through the steerable catheter, the MitraClip along with its delivery system is inserted and positioned by echocardiogram to the leaking portions of the valve. The clip is attached to the mitral valve leaflets, fastening them firmly together and allowing the valve to close better. Once the position of the clip is good with good reduction of the valve leak, the clip is released. One or more MitraClips may be used to fix a severely leaky valve. Patient will be given general anaesthesia during the entire procedure with TEE.

Advantage of MitraClip, a minimally invasive procedure as opposed to open heart surgery

• Enables faster recovery
• Reduction of hospital stay
• Better quality of life
• Improvement in the symptoms (shortness of breath and low pressure etc.)

Who can benefit from MitraClip?

• A good alternative for patients who are not candidates for open heart surgery
• An elderly patient or frail patient or a patient with a very weak heart
• Patient with a history of any other non-cardiac conditions involving the lungs, kidneys or brain
• Patients who previously underwent open heart surgery, due to higher risk for a re-operation

Case Studies

Case 1

Mr. N., 79-year-old male, known hypertensive was diagnosed to have mitral valve prolapse, with severe degenerative mitral regurgitation. Patient had complaints of severe cough at night. Echocardiography showed Mitral valve prolapse with severe mitral regurgitation. Considering the old age and valve leak, it was decided to proceed with MitraClip procedure. Transesophageal Echo assessment revealed that he was a suitable candidate for Mitra Clip procedure.

Mitra clip implantation was done under general anaesthesia by trans- femoral venous access. Under 3D-TEE guidance septal puncture was done. Pre-deployment mean pressure in left atrium was 24mmHg. Then one Mitra-Clip NT device was deployed across the P2 and A2 segment of mitral valve under fluoroscopy and 3D-TEE guidance. After confirming satisfactory positioning of the clip, it was released and the post deployment showed good positioning of the clip with very minimal mitral regurgitation. The mean gradient across was only 2 mmHg. His ECG, ECHO and hemodynamics were satisfactory after the procedure.

Patient had significant relief of symptoms immediately after the procedure and was discharged next day after the procedure

Case 2

Mr. R, 77-year-old gentleman, known hypertensive with previous heart problems who had undergone bypass surgery in 1994 and stenting few months ago, was diagnosed to have Mitral Valve Prolapse, with severe degenerative mitral regurgitation. Considering the old age and post bypass and post stenting status and the risk of redo- surgery, it was decided to do Mitra clip procedure. Transesophageal echo assessment revealed suitable anatomy for MitraClip procedure.

MitraClip implantation was done under general anaesthesia by trans- femoral venous access. Under 3D-TEE guidance septal puncture was done. Pre-deployment mean pressure in left atrium was 29mmHg. Then one Mitra-Clip NT device was deployed across the P2 and A2 segment of mitral valve under fluoroscopy and 3D-TEE guidance. After confirming satisfactory positioning of the clip, it was released and the post deployment showed good positioning of the clip with residual minimal mitral regurgitation. The mean gradient across was only 1mmHg. His ECG, ECHO and hemodynamics were satisfactory post procedure.

Patient was asymptomatic and was discharged in 48 hours after the procedure.