Francesco Maisano MD

Oct 23Oct 23rdrd 2008 2008Functional MR ptFunctional MR ptSan Raffaele HospitalSan Raffaele HospitalEquipeEquipe

Maisano, Michev, La Canna, Maisano, Michev, La Canna, Alfieri, ColomboAlfieri, Colombo

66 yo, male, 64 Kg, 164 cm, BSA 1.7 m2, BMI 24

Post-ischemic Cardiomyopathy, CCS II, NYHA III

Comorbidities

Infrarenal abdominal aneurysm

2006 stenting of right common carotid artery and right internal carotid artery

2005 Bone Marrow Tx for AML

1994 anterior AMI; 2001 PCI followed by CABG (LIMA—LAD), followed by multiple

PTCA with DES

1/2008: AMI for intrastent thrombosis -> POBA on LAD

4/2008 Acute Pulmonary Edema CRT with Biventricular Pacing and ICD

Log ES: 45%; STS risk 20%

Dilated ischemic cardiomyopathy LVEDV: 211ml LVESV: 165 ml

Severe LV dysfunction (EF 20%)Severe MR (ERO 0,2 cm2) Severe tethering

▪ TA 4,1 cm2; CD 1,7 cm

Annular dilatation▪ SL 38 mm; IC 46 mm);

Severe Pulmonary Hypertension (75mmHg), RV failure, Moderate tricuspid regurgitation

Central MR MR jet width below

1.5 cm Coaptation length >3

mm Coaptation depth 1.7

Right femoral vein access Right femoral vein access with a 6F introducerwith a 6F introducer

Left femoral artery with a 6 F Left femoral artery with a 6 F introducerintroducer Pigtail in the ascending aortaPigtail in the ascending aorta

Standard transeptal Standard transeptal puncture setuppuncture setup

Line ofcoaptation

3.5 cm3.3 cm

Extra Stiff Amplatz exchange length wire (.035”) in upper PV or large loop in LA through the Mullins sheath

CoilsCoils

Guide Marker

LA

RA

Guide Marker

AmplatzGuide

Requires a Controlled, Systematic & Requires a Controlled, Systematic & Iterative approachIterative approach

Imaging guidanceImaging guidance Primarily Echocardiography (aided by Primarily Echocardiography (aided by

Fluoroscopy)Fluoroscopy) 3-D positioning using 4 key echo views 3-D positioning using 4 key echo views

▪ LVOT and (Inter-) Commissural viewsLVOT and (Inter-) Commissural views▪ SAX at base and TG-SAX viewsSAX at base and TG-SAX views

Position adjustmentsPosition adjustments Multiple “controls” availableMultiple “controls” available

▪ Knobs; Torque; TranslationKnobs; Torque; Translation

Soft tip of guide

Clip

Guide Marker

SleeveMarkers

Guide

Steerable sleeve

Clip delivery handle

Stabilizer

Atrial Septum

Guide

Steerable sleeve

Clip delivery handle

Stabilizer

Atrial Septum

A high risk surgical candidate has been submitted to Mitraclip procedure to treat FMR

The patient was transferred from ICU to the general ward in day 1 and discharged home 4 days after the procedure

At 3 months the MR reduction is stable with mild residual MR, reduction of LV volumes, and the patient is in NYHA class II