- 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.