Herrmann v1.qxp 16/7/08 10:12 Page 40
Interventional Cardiology
Figure 1: Causes of Chronic Mitral Regurgitation Figure 4: 3D Transesophageal Echocardiographic Images Obtained
During a MitraClip
®
Procedure
Chronic MR
Congenital Degenerative Functional
Cleft Myxomatous Dilated CM
Accessory orifice Rheumatic HOCM
Anamolous arcade Endocarditic Ischemic
Short chordae Drug-induced
CT diseases
In the left panel, one can see the clip delivery system in the left atrium (arrow) after a clip has
Annular calcific been placed to create edge-to-edge leaflet apposition. This image is similar to what a surgeon
sees looking at the valve after opening the left atrium. In the right panel, the double orifice after
placement of two clips (arrows) is visible in the transgastric view.
CT = connective tissue; HOCM = hypertrophic obstructive cardiomyopathy; CM = cardiomyopathy.
Figure 2: Sequence of Transesophageal Echocardiographic Views
During a MitraClip
®
Procedure
patients was 71 years, and 61% were 65 years of age or older.
Degenerative disease was present in most patients, but 22% had a
functional etiology. A single clip was placed in most patients, 11% did not
have a clip placed, and two clips were used in 29% of patients.
Complications related to the procedure were quite low, especially when
one considers that this cohort included the earliest procedures at each
institution. There were no deaths, and 97% of patients were discharged
without the need for home healthcare. The rate of 30-day major adverse
events, not including blood transfusion, was 3%. Although there were no
cases of clip embolization, partial clip detachment occurred in nine
patients (9%), but all cases occurred within the first 30 days and were
managed successfully with elective surgery. Acute procedural success,
defined as a successful clip implantation with core echocardiographic
In the top row, from left to right, are posterior leaflet prolapse into the left atrium, a short-axis
laboratory assessment of MR <2+ at discharge, was achieved in 85% of
view at the base demonstrating trans-septal insertion of the guide catheter, and the MitraClip
®
in
its open position in the left atrium poised to be advanced into the left ventricle. In the bottom
this initial cohort of patients. Follow-up of these patients demonstrated a
row, the MitraClip is open in the left ventricle just prior to grasping the leaflets (left panel). The
durable result in the majority of patients to three years (see Figure 3). In
bottom middle and right panels show two clips deployed on the leaflets to create a double orifice
with two color flow jets of mitral inflow visible (right).
6 addition, significant reverse left ventricular remodeling confirmed that a
benefit of MR reduction was achieved.
12
Figure 3: Event-free Kaplan-Meier Curves
100%
100%
99%
97% 97% 97% 97%
Discussion
ess
cc
90%
87%
85%
86% 86%
86% 85%
Use of the MitraClip system to repair mitral regurgitation on a
c
al su
80%
beating heart without surgery is feasible, safe, and effective. Keys to the
72%
c
lini
68% 68%
68% 67%
success of this procedure include careful patient selection and a
60%
Reached
collaborative interdisciplinary team approach with echocardiographer,
79 68 61 42 36 28 =
end-point
anesthesiologist, and interventionalist. Future refinements in both the
0%
technology and imaging are likely to improve efficacy and further simplify
0 6 12 18 24 30 36 42
Time (months)
the procedure. Realtime 3D transesophageal imaging has recently
Probability of event-free Freedom from Freedom from Freedom from death, become available.
13
With this technique, improved visualization of the
death surgery surgery, or MR >2+
MitraClip delivery system can be achieved, providing the interventionalist
Curves are shown for 79 patients with acute procedural success.Freedom from death (blue),
with an ‘en-face’ or ‘surgeon’s view’ of the mitral apparatus and allowing
surgery (brown), and the composite of death, surgery, and MR >2+ (purple) are shown for three the operator to better co-ordinate steering of the device in 3D space (see
years of follow-up. Acute procedural success is defined as successful placement of one or two
clips with MR <2+ at discharge echocardiogram, as determined by the core laboratory.
Figure 4). ■
1. Enriquez-Sarano M, Avierinos JF, Masika-Zeitoun D, et al., New Eng 6. Herrmann HC, Feldman T, Euro Intervention, 2006;1(Suppl. A): 10. Feldman T, Wasserman HS, Herrmann HC, et al., J Am Coll Cardiol,
J Med, 2005;352:875–83. A36–9. 2005;46:2134–40.
2. Bonow RO, Carabello BA, Chatterjee K, et al., Circulation, 7. Maisano F, Caldarola A, Blasio A, et al., J Thorac Cardiovasc Surg, 11. Feldman T, Foster E, Tunuguntla A, et al., J Am Coll Cardiol,
2006;114:e84–231. 2003;126:1987–97. 2007;49(Suppl. A):310A.
3. Goodney PP, Stukel TA, Lucas FL, et al., Hospital Volume, Ann Surg, 8. Silvestry FE, Rodriguez L, Herrmann HC, et al., J Am Soc 12. Carabello BA, Kar S, Rinaldi M, et al., Circulation, 2007;116
2003;238:161–7. Echocardiog, 2007;20:1131–40. (Suppl. 2):357.
4. David TE, Semin Thorac Cardiovasc Surg, 2007;19:116–20. 9. Foster E, Wasserman HS, Gray W, et al., Am J Cardiol, 13. O’Gara P, Sugeng L, Lang R, et al., J Am Coll Cardiol Img,
5. Feldman T, Leon MB, Circulation, 2007;116:2866–77. 2007;100:1577–83. 2008;1:221–37.
40 US CARDIOLOGY
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