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

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.

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

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

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

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

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

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

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

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

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

Move clip delivery system in until it straddles guide

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

Torque Guide Clockwise=Posterior Counter Clockwise=Anterior

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

Torque Guide

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

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

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

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

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)

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

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

First grasp – MR moderate

Second and several subsequent grasps – Missed Posterior Leaflet

Final grasp – leaflet grasp stable

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

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

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

Clip closed Both leaflets grasped SAX double orifice