MITRACLIP. TEER (Trancatheter Edge-to-Edge Repair of the Mitral leaflet)
- used for treatment of mitral regurgitation (MR), based on the surgical procedure pioneered by Ottavio Alfieri (double orifice valve)
- made of a cobalt–chromium alloy and covered with polypropylene fabric to promote tissue in-growth
- has a dual-arm structure, with grippers above the arms to assist with capture of the mitral valve leaflets and their approximation while the heart is beating.
- Indicated for high surgical or inoperable patients with MR 3+ and 4+
- preserves the option for future percutaneous intervention or surgical procedures
MITRACLIP Procedure
1 Steerable guide catheter
1 Clip delivery system
1 Stool/Booster
1 Booster support plate
1 Sterile stabiliser
80cm - measurement from mid-chest to foot stool
Big trolley (MITRACLIP trolley)
4 3-way taps
4 bionector (CARESITE Luer access device)
2 1000mL Heparinised saline (1,000 iu per 1L bag)
2 giving sets
2 50mL luerlock syringes
2 pressure bags
1 drip stand
Scrub trolley
1 Barts TAVI pack
1 COOK femoral needle
1 8F femoral sheath
1 14F short femoral sheath
2 big Chlorapreps
2 pressure lines
1 JR4 diagnostic catheter
1 Ultrasound probe cover
1 500mL saline bag
1 Amplatz super stiff wire (straight tip, short taper)
2 60mL luerlock syringe
2 Proglide
1 Backstop
1 1L sterile H20 bottle
1 10,000iu Heparin
1 20mL Lidocaine 1%
Transseptal kit
1 BRK 71cm transseptal needle
1 SL1 introducer sheath (St Jude)
2 types of MR:
- degenerative MR - intrinsic valve lesions
- functional MR - secondary
MR leads to LV dysfunction and heart failure.
Pre-op tests:
* Stress echo
* TOE
* Cardiac MRI
* Bloods esp group and screen
* 12 L ECG
Extras: (for additional clips)
* 1000ml saline (2sets for each clip)
* 1000ml pressure bags (2sets for each clip)
* Sterile giving sets
* 3way stopcocks (3pcs for each clip)
Preps:
* place support plate under mattress, under right foot
* Lift/stool should be placed on top of support plate and positioned 80cm from midsternum
* Place pressure pads for both feet
* Have incupads ready to place on floor for overflow of salineflush.
Steps:
- Prepare patient (ET, central line, arterial line, urinary catheterisation)
- Insert 7F sheath into right femoral vein. (Insert 5f sheath and proglide if applicable.)
- Sequential dilation: Upsize to biggest sheath available (12-22F).
- Do Transeptal puncture under echo and fluorguidance. Insert extra stiff wire (amplatz or safari wire) and keep on LA. (If tricuspid valve, no need for transeptal puncture).
- Give heparin.
- Position stabilizer on top of stool
- At back table, prepare and flush dilator and guide cath.
- Once ready, remove sheath and insert dilator with guide cath. Remove dilator.
- Once the guide cath is in. Prepare and de-air the CDS.
- Insert CDS into the left atrium.
- Position CDS directly above the regurgitant jet and advance across the MV into the LV
- The Clip is retracted toward the MV leaflets to engage the appropriate segments of the MV. Clip should be Perpendicular to MV.
- The grippers are dropped and arms of the Clip are closed.
- If the leaflet insertion visualised on TOE is acceptable, the degree of residual MR is assessed with the Clip fully closed.
- If reduction is inadequate, the Clip may be released and repositioned or a second clip may be implanted.
- If second or more clips are needed, prepare CDS and prepare extras (see above)
- After the Clip(s) are deployed, the CDS and GC are removed from the patient.
- Manual compression, proglide or figure of 8 sutures may be used to close the femoral vein access site.
Complications:
* LA/ LAA perforation
* Pericardial effusion
* Arrhythmias
* Clip in LV
* Flail leaflet/chords
* Vascular access: Bleeding/ fistula
* Infection
Notes:
- If MR is still present in echo after deployment, patient may have additional clips or may require surgical repair.
- Patient with mitraclip should have prophylactic antibiotics before any medical/dental procedure.
