Transesophageal Echocardiography During MitraClip® Procedure

Intracardiac echocardiography to enable successful edge-to-edge transcatheter tricuspid valve repair in patients with insufficient TEE quality

BACKGROUND

Transesophageal echocardiography (TEE) as a guiding tool for edge-to-edge transcatheter tricuspid valve repair (EETVr) using MitraClip (Abbott Vascular, Santa Clara, USA) may not offer sufficient image quality in a significant proportion of patients.

OBJECTIVES

Intracardiac echocardiography (ICE) as additional guiding tool in EETVr with the MitraClip device.

METHODS

Appropriate angulations of the ICE catheter to visualize each commissure of the tricuspid valve were established in 3D printed heart models. In a single tertiary-care center ICE was used to support EETVr as additional guidance when TEE image quality was insufficient. Procedural safety and outcomes up to 30-days were compared between ICE/TEE and TEE only guided patients.

RESULTS

In 6 of 11 patients (54.5%) undergoing EETVr with MitraClip TEE alone was unsatisfactory, necessitating additional ICE guidance. In 4 of these 6 patients ICE enabled a successful completion of the procedure. The steering maneuvers identified in the 3D models were well applicable in all patients, providing examples for potential future ICE implementation in EETVr. Under both TEE alone (n = 5) and ICE (n = 6) guidance the rate of procedural complications was 0%. According to vena contracta values at discharge significant TR reduction was achievable in the treated cohort (p = 0.011). At 30-days follow-up one patient (ICE guided) died following global heart failure, not associated with the procedure itself.

CONCLUSIONS

ICE guidance may offer an additional tool to guide EETVr with the MitraClip device in patients with poor TEE quality, as it enables successful results without impairing procedural safety.

New developments in transcatheter therapy of mitral valve disease

Mitral valve regurgitation (MR) belongs to one of the most common acquired valve diseases in western countries with increasing prevalence in older age. For patients with high perioperative risk and older age prohibitive for valve surgery, the development of transcatheter mitral valve therapies offers new options. Assessment of the severity and etiology of MR and thorough imaging of the mitral valve anatomy and pathology are necessary prerequisites for appropriate decision making in the field of transcatheter mitral valve therapies. Different transcatheter repair and replacement techniques are on the market, most of them mimicking surgical techniques. With some techniques (e.g., the MitraClip device), there is good clinical experience (>80,000 devices implanted worldwide), and evidence (three randomized studies), whereas for newer procedures, safety and efficacy data are still very limited. Transcatheter mitral repair and replacement techniques have to be considered as complementary treatment options for high-risk patients indicated by the Heart Teams. The different techniques and devices will be introduced and discussed in the following paper.

Transcatheter Mitral Valve Repair Using the Edge-to-Edge Clip

Percutaneous intervention for mitral valve (MV) disease has been established as an alternative to open surgical MV repair in patients with prohibitive surgical risk. Multiple percutaneous approaches have been described and are in various stages of development. Edge-to-edge leaflet plication with the MitraClip (Abbott, Menlo Park, CA) is currently the only Food and Drug Administration-approved device specifically for primary or degenerative lesions. Use of the edge-to-edge clip for secondary mitral regurgitation is currently under investigation and may result in expanded indications. Echocardiography has significantly increased our understanding of the anatomy of the MV and provided us with the ability to classify and quantify the associated mitral regurgitation. For percutaneous interventions of the MV, transesophageal echocardiography imaging is used for patient screening, intraprocedural guidance, and confirmation of the result. Optimal outcomes require the echocardiographer and the proceduralist to have a thorough understanding of intra-atrial septal and MV anatomy, as well as an appreciation for the key points and potential pitfalls of each of the procedural steps. With increasing experience, more complex valvular pathology can be successfully percutaneously treated. In addition to two-dimensional echocardiography, advances in three-dimensional echocardiography and fusion imaging will continue to support the refinement of current technologies, the expansion of clinical applications, and the development of novel devices.

Role of 3D Echocardiography in Cardiac Surgery: Strengths and Limitations

PURPOSE OF REVIEW

This review aims to highlight the general and specific strengths and limitations of intraoperative 3D echocardiography. This article explains the value of real-time three-dimensional transesophageal echocardiography (RT 3D TEE) during cardiac surgery and cardiac interventions.

RECENT FINDINGS

Recently published recommendations and guidelines include the use of RT 3D TEE. RT 3 D TEE provides additional value particularly for guidance during cardiac interventions (i.e., transcatheter mitral valve repair, left atrial appendix and atrial septal defect closures), assessment of the mitral valve in surgical repair, measurement of left ventricular outflow tract area for transcatheter valvular replacements, and estimating right and left ventricular volumes and function. The exact localization of paravalvular leakage is another strength of RT 3D TEE. The major limitation is the reduced temporal resolution compared to 2D TEE.

SUMMARY

Three-dimensional echocardiography is a powerful tool that improves communication and accurate measurements of cardiac structures.

An update on intraoperative three-dimensional transesophageal echocardiography

Transesophageal echocardiography (TEE) was first used routinely in the operating rooms in the 1980s to facilitate surgical decision-making. Since then, TEE has evolved from the standard two-dimensional (2D) exam to include focused real-time three-dimensional (RT-3D) imaging both inside and outside the operating rooms. Improved spatial and temporal resolution due to technological advances has expedited surgical interventions in diseased valves. 3D imaging has also emerged as a crucial adjunct in percutaneous interventions for structural heart disease. With continued advancement in software, RT-3D TEE will continue to impact perioperative decisions.

Our Anaesthetic Experiences in Patients Undergoing Percutaneous Mitraclip Implantation

OBJECTIVE

Percutaneous mitraclip implantation system, is a new technique developed for patients with high surgical risks. It is generally performed in a catheterisation laboratory with the guidance of fluoroscopy and transesophageal echocardiography. In this study, we aimed to share our experiences on anaesthetic in patients undergoing mitraclip implantation under general anaesthesia.

METHODS

Eighty four patients with severe, symptomatic mitral insufficiency, who had undergone MitraClip implantation under general anaesthesia between July 2012 and March 2015 (54 male, 30 female; mean age: 68.5±10.2 years) were retrospectively investigated in terms of anaesthetic management.

RESULTS

Of the 84 patients undergoing percutaneous mitraclip implantation under general anaesthesia, 84.5% had sodium thiopental and 75% had midazolam for anaesthesia induction. For the maintenance of anaesthesia, 57% of the patients were reported to have sevoflurane, whereas the rest had desflurane. The mean duration of the procedure and anaesthesia was 140.9±48.2 mins and 165.7±50.6 min, respectively. Seventy seven patients were transported to the intensive care unit and intubated after the procedure. The median extubation time was 3 h. Length of stay in the intensive care unit was 2 days, whereas it was 4 days for hospital stay. One patient died during the procedure and six patients died after the procedure.

CONCLUSION

Percutaneous mitraclip implantation procedure is quite difficult for anaesthesiologists because of the procedure itself and the population on which the procedure is performed. The primary aim of anaesthesia management is to provide haemodynamic stability. The preoperative preparation and anaesthesia methods should be the same as for patients undergoing cardiac surgery. It is reported that as the experience regarding this subject increases, success of the procedure increases, with better protected haemodynamic stability, less inotropic and vasopressor requirement and shorter length of hospital stay.

Echocardiographic Imaging of the Mitral Valve for Transcatheter Edge-to-Edge Repair

Echocardiography continues to be the most effective imaging tool for the diagnosis and follow-up of mitral valve disease. This review addresses the use of transthoracic echocardiography and transesophageal echocardiography in the planning and guidance of transcatheter mitral valve therapies. Many of the echo-imaging guidance techniques are applicable to transcatheter intervention as a whole. However, given that the MitraClip is the only device approved for mitral regurgitation at present, specific attention is paid to this procedure, with additional focus on the guidance of noncentral repair. The imaging techniques discussed will be applicable to future devices.

Transcathether Valve Replacement and Valve Repair

Transcatheter aortic valve replacement for treatment of aortic stenosis has now become an accepted alternative to surgical valve replacement for some patients. In addition, transcatheter mitral valve repair is also routinely used in high surgical risk patients with mitral regurgitation. Other transcatheter procedures are in rapid development. The current review attempts to summarize the procedures and echocardiographic imaging used for transcatheter valve replacement or valve repair.

Perioperative management of a patient undergoing a novel mini-invasive percutaneous transcatheter left ventricular reconstruction procedure

Survivors of myocardial infarction might have residual damage and higher risks of developing heart failure. This increasing complication encompasses up to 45% of all infarcts. As anesthesiologists we will have to perform anesthesia more frequently in patients with such challenging medical history schedule to undergo mini-invasive surgical procedures. We present the case of a 51-year-old man with severe heart failure post-myocardial infarction with multiple sclerosis undergoing a novel percutaneous transcatheter ventricular reconstruction via a left mini-thoracotomy. To guide the surgeon during the intervention we used a real-time 3D echocardiography, enlightening the fact that guidance is crucial for that kind of procedure. To lower postoperative pain and the inflammatory response we have administered successfully intravenous lidocaine, indicating that it is possible to avoid regional anesthesia in patients with multiple sclerosis scheduled for mini-invasive left ventricular reconstruction requiring a mini-thoracotomy.

Comparison of Percutaneous Mitral Valve Repair Versus Conservative Treatment in Severe Functional Mitral Regurgitation

Percutaneous mitral valve repair (PMVR) using the MitraClip System is feasible and entails clinical improvement even in patients with high surgical risk and severe functional mitral regurgitation (MR). The aim of this study was to assess survival rates and clinical outcome of patients with severe, functional MR treated with optimal medical therapy (OMT) compared with those who received MitraClip device. Sixty patients treated with OMT were compared with a propensity-matched cohort of 60 patients who underwent PMVR. Baseline demographics and echocardiographic variables were similar between the 2 groups. The mean age of patients was 75 years, and 67% were men. The median logistic EuroSCORE and EuroSCORE II were 17% and 6%, respectively, because of the presence of several co-morbidities. The mechanism of MR was functional in all cases with an ischemic etiology in 52% of patients. Median left ventricle ejection fraction was 34%. All the patients were symptomatic for dyspnea with 63% and 12% in the New York Heart Association class III and IV, respectively. In PMVR group, the procedure was associated with safety and very low incidence of procedural complications with no occurrence of procedural and inhospital mortality. After a median follow-up of 515 days (248 to 828 days), patients treated with PMVR demonstrated overall survival, survival freedom from cardiac death and survival free of readmission due to cardiac disease curves higher than patients treated conservatively (log-rank test p = 0.007, p = 0.002, and p = 0.04, respectively). In conclusion, PMVR offers a valid option for selected patients with high surgical risk and severe, functional MR and entails better survival outcomes compared with OMT.

Recent advances in echocardiography for valvular heart disease

Echocardiography is the imaging modality of choice for the assessment of patients with valvular heart disease. Echocardiographic advancements may have particular impact on the assessment and management of patients with valvular heart disease. This review will summarize the current literature on advancements, such as three-dimensional echocardiography, strain imaging, intracardiac echocardiography, and fusion imaging, in this patient population.

Management of organic mitral regurgitation: guideline recommendations and controversies

Mitral regurgitation (MR) represents the second most frequent valvular heart disease. The appropriate management of organic MR remains unclear in many aspects, especially in several specific clinical scenarios. This review aims to discuss the current guideline recommendations regarding the management of organic MR, while highlighting the controversial aspects encountered in daily clinical practice. The role of imaging is essential in establishing the most appropriate type of surgical treatment (repair or replace), which is based on morphological mitral valve (MV) characteristics (reparability of the valve) and local surgical expertise in valve repair. The potential advantages of 3-dimensional echocardiography in assessing the MV are discussed. Other modern imaging techniques (tissue Doppler and speckle tracking) may provide additional useful information in borderline cases. Exercise echocardiography (evaluating MR severity, pulmonary pressure, or right ventricular function) may have an important role in the management of difficult cases. Finally, the moment when surgery is no longer an option and alternative solutions should be sought is also discussed. Although in everyday clinical practice the timing of surgery is not always straightforward, some newer clinical and echocardiographic indicators can guide this decision and help improve the outcome of these patients.