Transseptal access for left heart structural interventions in the setting of prior atrial septal defect closure

A transseptal puncture is critical for "left-sided" structural heart interventions. Procedures such as transcatheter edge-to-edge repair (MitraClip) and left atrial appendage (LAA) closure (Watchman) require precise puncture of the interatrial septum (IAS), and the presence of a prior atrial septal defect (ASD) closure device poses a challenge. We aim to present a successfully completed case of MitraClip and Watchman in the presence of ASD closure device in two different patients. A review of the literature will be reported, and pertinent clinical and technical considerations will be discussed in depth to achieve procedural success. In summary, transseptal puncture for left heart structural interventions is feasible in the presence of a prior ASD/patent foramen ovale closure device. A detailed understanding of the anatomical considerations as well as the use of multimodality imaging to evaluate the IAS will aid in improving procedural success rates.

Retrieval of a MitraClip from the left atrium using a two-snare technique: Case report and review of the literature

MitraClip is used for reduction of mitral insufficiency in patients who are not good surgical candidates, but with expanding indications, the use of MitraClip and the number of complications will increase. Here is presented a case of a single leaflet device attachment that worsened the patient's mitral insufficiency, as well as the technique for stabilizing the valve followed by retrieval of the device. A special focus is placed on removing the using a two-snare technique to avoid the need for a surgical cutdown and repair.

Transcatheter Mitral Valve Direct Annuloplasty with the Millipede IRIS Ring

Mitral valve ring annuloplasty is a surgical gold standard and is used routinely during surgical mitral valve repair of primary or secondary mitral regurgitation. The Millipede IRIS annuloplasty ring is the first transcatheter, transfemoral, transseptal, semirigid, complete annuloplasty ring to be delivered to the mitral valve annulus. Initial results in humans demonstrate that the Millipede IRIS ring is safe, and can effectively reduce the mitral annular diameter leading to a clinically significant reduction or elimination of mitral regurgitation.

Usable implantation depth for watchman left atrial appendage occlusion is greater with appendage angiography than transesophageal echocardiography

OBJECTIVES

To compare left atrial appendage (LAA) angiography to transesophageal echocardiography (TEE) for assessing usable LAA depth.

BACKGROUND

TEE is typically employed for procedural measurement of LAA ostial diameter and depth. Since angiography enhances distal LAA anatomy, we sought to compare angiography to TEE for determining usable LAA depth.

METHODS

Seventy five Watchman device cases were retrospectively evaluated. Two independent cardiologists measured intraoperative LAA ostial diameter and depth at standard 0°, 45°, 90°, and 135° TEE omniplane views and in the right anterior oblique (RAO) 30°, caudal (CAUD) 30° angiographic view.

RESULTS

The average age and CHA₂ DS₂ VASc score were 74 (±7.2) years and 4.6 (±1.3), respectively. The average ostial diameter and depth (mm) by TEE were 0°: 19.6 and 26.5; 45°: 17.5 and 26.6; 90°: 18.3 and 25.1; 135°: 19.5 and 23.3. The ostial diameter and depth (mm) by RAO 30° CAUD 30° angiography were 21.1 and 29.7. This angiographic view corresponds to a TEE view between 90° and 135°. In comparison to angiography, TEE 90° underestimated the LAA ostial diameter by 2.9 ± 3.7 mm (P < 0.001) and by 1.9 ± 4.0 mm at TEE 135° (P < 0.01); Pearson's r 0.53 angiography/TEE 90° and 0.50 angiography/TEE 135°. More importantly, TEE 90° underestimated the true usable LAA depth by 5.4 ± 5.8 mm (P < 0.001) and by 7.3 ± 6.1 mm at TEE 135° (P < 0.001); Pearson's r 0.39 angiography/TEE 90° and 0.30 angiography/TEE 135°.

CONCLUSIONS

Compared to TEE, LAA angiography provides additional depth information and may be particularly valuable when patients have insufficient depth for Watchman by TEE measures.

Early clinical results with the Tendyne transcatheter mitral valve replacement system

Transcatheter mitral valve replacement is an emerging technology for the treatment of mitral valve regurgitation. Numerous devices are in development and in various stages of clinical investigation. The Tendyne system (Tendyne Holdings, LLC, a subsidiary of Abbott Vascular, Roseville, Minnesota) is a fully repositionable and retrievable, transapical transcatheter mitral valve replacement platform. The results of the early feasibility studies in the U.S. are highly encouraging and a pivotal randomized trial is underway. The Tendyne transcatheter mitral valve replacement valve may prove to be a safe, less invasive approach to treatment of mitral valve disease.

Early experience with Millipede IRIS transcatheter mitral annuloplasty

The IRIS mitral annuloplasty ring is a transcatheter, transfemoral and transseptal-delivered complete, semi-rigid annuloplasty ring. The IRIS system mimics surgical annuloplasty by reducing the mitral septal-lateral dimension and improving leaflet coaptation. We report the early experience with the IRIS system in seven patients. These patients had 3-4+ mitral regurgitation (MR) with annular dilation and were symptomatic NYHA II-IV with LV end systolic dimensions ≤65 mm. Patients were excluded for LVEF <20%, aortic valve disease, right-sided heart failure and PA systolic pressure >70 mmHg. Baseline and 30-day transthoracic echocardiography and CT imaging was performed. In phase 1, 4 patients had surgical IRIS mitral ring implantation. In phase 2, 3 patients had transfemoral, transseptal delivery of the IRIS mitral ring. There was no procedural death, or MI. The mitral SL diameter was reduced from 38.0±4.1 to 25.9±4.9 mm at 30 days (31.8% SL reduction, n=7). MR was reduced from baseline 3-4+ to 0-1+ in all patients at 30 days. There were improvements in NYHA class and there was a decrease in diastolic LV volumes from 182.4±54.3 to 115.3±98.8 mL at 30 days (36.8% reduction). Based on these initial positive findings, ongoing clinical trials are underway to further evaluate the safety and efficacy of the IRIS ring.

Percutaneous Tricuspid Annuloplasty

The tricuspid valve was ignored for a long time. The prevalence of severe tricuspid regurgitation is not negligible, however, and is associated with poor prognosis. In cases of primary tricuspid regurgitation, surgical options are limited by a high risk of mortality and morbidity. New percutaneous approaches are becoming available to meet this consistent unmet clinical need. This review presents the current available devices that reproduce both the complete and uncomplete surgical annuloplasty techniques.

Mitral stenosis due to dynamic clip-leaflet interaction during the MitraClip procedure: Case report and review of current knowledge

The goal of MitraClip therapy is to achieve mitral regurgitation reduction without iatrogenic creation of clinically significant MS. In some series, up to 35% of patients are left with mild MS. There are many contributors to the final transmitral gradient achieved in patients undergoing MitraClip therapy. Additionally, there are many modalities used for the intraprocedural assessment of MS with no one modality considered to be the benchmark. We herein describe a case which illustrates the dynamic nature of clip-leaflet interaction, and review intraprocedural techniques for invasively and noninvasively assessing MS.