Transcatheter Mitral Valve Implantation (TMVI)

under General Anaesthetic

TOE guided

Bloods: Group and screen

Barts TAVI (Celovska) pack

6Fr femoral sheath (arterial)

8Fr femoral sheath (venous)

14Fr femoral sheath

26Fr Gore Dryseal femoral sheath (venous) (33cm length)

Proglide x 2

6F MPA1 diagnostic catheter

6F JR4 diagnostic catheter 

25mm gooseneck snare

J-tip Terumo 260cm wire

Safari wire

Pacing wire

crossing system:

BAYLIS VersaCross Transseptal System

or BRK (71cm) Transseptal needle

SL0 Transseptal guiding introducer

12mm or 14mm Z-Med balloon (to dilate atrial septum)

Contrast mixture: (15:85) for Edwards S3 commander system valve. Orientation: Skirt towards LA (opposite of Transfemoral TAVI)

15mL Contrast

85mL Saline

Procedure Steps:

This procedure was performed in a hybrid CathLab under general anesthesia. 

6F femoral sheath to femoral artery.

Insert 6F JR4 diagnostic catheter plus 25mm Gooseneck snare.

An 8-French (Fr) sheath was inserted in the left femoral vein. 

A transvenous pacemaker was advanced through this sheath and positioned in the right ventricular apex. 

After right femoral venous access was obtained, 1 pre-close suture in the femoral vein was deployed using ProGlide

Edwards E-Sheath was inserted next

A trans-septal puncture was performed under TOE guidance in a “high” and “posterior” position in the fossa ovalis. 

The SL0 sheath was advanced into the left atrium and a bolus of heparin was administered for a total of 100 IU/kg [target activated clotting time (ACT) 250–300 s]. 

An Agilis™ catheter was advanced over a normal guidewire or a ProTrack pigtail wire into the left atrium and directed over the mitral valve. 

A 5 Fr Multipurpose catheter was advanced over a standard 0.035” guidewire through the Agilis catheter. 

Using TOE and fluoroscopy for guidance, the multipurpose catheter was advanced across the valve into the LV apex. 

The standard guidewire was then exchanged for a 0.035” Confida Wire which was positioned in the LV apex. 

Getting adequate and stable guidewire position is crucial to a successful procedure. 

Subsequently, the interatrial septum was subsequently dilated with a 10–12 mm peripheral balloon through the Agilis sheath and “flossed” across the septum to ensure adequate space for the transcatheter delivery system to cross the septum. 

The Agilis sheath and balloon were then removed. 

A SAPIEN3 valve was mounted for antegrade implantation and the delivery was advanced into the inferior vena cava. 

*This is an important step to ensure that the SAPIEN3 valve is mounted 180 degrees from the orientation typically used for transcatheter aortic valve replacement (TAVR) procedures; an inappropriately mounted valve would have dire consequences. 

The valve was docked and aligned on the deployment balloon in the inferior vena cava before being advanced across the atrial septum. 

The transcatheter valve deployment system was flexed and oriented towards the mitral valve and positioned across the mitral valve prosthesis in a fluoroscopic view perpendicular to the bioprosthesis and confirmed with TOE. It is important to obtain coaxial alignment with the bioprosthesis. The atrial aspect of the transcatheter valve should overlap with the bioprosthetic sewing ring—each valve appears has a unique fluoroscopic appearance and it is imperative for operators to know the exact location of the sewing ring on which a sealing zone is created. The objective is to have approximately 20% of the transcatheter valve in the left atrium and 80% in the left ventricle. The valve was deployed with slow balloon inflation under rapid ventricular pacing at 180–200 bpm. Slow balloon inflation allows for real-time adjustment of the transcatheter valve during deployment. The final position was assessed fluoroscopically and with TOE.

Completion

After valve deployment, the transcatheter valve deployment system was removed. 

A multipurpose catheter was then advanced into the LV to allow atraumatic removal of the Confida wire. 

The sheath was then removed and the right femoral venous Perclose was secured. 

In this case, protamine was administered, the transvenous pacer was removed, and manual compression was held after the left femoral venous sheath was removed.