Difference between revisions of "Transcatheter mitral valve replacement"

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{{Infobox surgical procedure
| anesthesia_type = GA
| airway = ETT
| lines_access = 2 PIVs, pre-induction arterial line
| monitors = Standard, intraoperative TEE
| considerations_preoperative = Symptoms of MR, functional capacity, dysphagia/prior gastrointestinal procedures (use of TEE intraoperatively)
| considerations_intraoperative = Hemodynamic management, continuous intraoperative TEE to guide device placement, anticoagulation
| considerations_postoperative =
}}


Transcatheter mitral valve replacement (TMVR) is a minimally invasive approach in which a prosthetic mitral valve is implanted through a transapical or transseptal approach to treat severe mitral valve disease in patients who are not suitable candidates for surgery or transcatheter edge-to-edge repair (TEER).
Transcatheter mitral valve edge-to-edge repair (TEER) is a minimally invasive approach to treat mitral regurgitation (MR) in patients who are at high or prohibitive surgical risk. The procedure involves percutaneous insertion of a clip device via the femoral vein, transseptal puncture, and deployment across the mitral valve leaflets under transesophageal echocardiographic (TEE) and fluoroscopic guidance. The clip approximates the anterior and posterior mitral leaflets at the site of regurgitation, reducing the severity of MR.
Main Types of TEER:
* MitraClip (Abbott)
* Pascal (Edwards)
== Overview ==
=== Indications ===
* Severe symptomatic primary (degenerative) mitral regurgitation
* Moderate-to-severe or severe symptomatic secondary (functional) mitral regurgitation who remain symptomatic despite maximally tolerated guideline-directed medical therapy
=== Surgical procedure ===
* Right femoral venous access
* Transseptal puncture to access left atrium
* Guide catheter and clip delivery system is navigated across mitral valve
* Device positioned perpendicular to mitral leaflet coaptation, targeting area of maximal regurgitant jet, clip arms opened and advanced into left ventricle, then retracted to grasp both the anterior and posterior mitral leaflets
* Confirm leaflet capture by TEE
* Additional clips may be placed to optimize results
* Guide catheter and clip delivery system removed
* Achieve hemostasis at access site
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Symptoms of mitral regurgitation, functional capacity
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
* Type and screen
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
* Infusion and bolus vasopressors
** Norepinephrine gtt
** Phenylephrine, ephedrine, push dose epinephrine
* Heparin and protamine
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
== Intraoperative management ==
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* Pre-induction arterial line
* 2 peripheral IVs
** Infusion line
** Bolus line
* Intraoperative transesophageal echocardiography (TEE)
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
Standard induction, endotracheal intubation
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
Supine, arms tucked
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* Maintaining hemodynamic stability
** Avoiding hypotension and tachycardia, which can worsen mitral regurgitation
* Continuous transesophageal echocardiography to guide device placement and assess mitral regurgitation reduction
* Systemic heparinization to prevent thromboembolic events
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
== Postoperative management ==
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
Cardiology floor with telemetry
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
Minimal pain anticipated, often related to positioning or groin access site.
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Bleeding
* Pericardial tamponade
* Vascular injury
* Device specific complications
** Single leaflet device attachment
** Device embolization
** Loss of leaflet insertion
* Stroke
* Myocardial infarction
* Left ventricular thrombus formation
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Transcatheter mitral valve replacement (TMVR)
!Transcatheter edge-to-edge repair (TEER)
|-
|Unique considerations
|
|
|-
|Position
|
|Supine
|-
|Surgical time
|
|2-3 hours
|-
|EBL
|
|Minimal
|-
|Postoperative disposition
|
|Floor with telemetry
|-
|Pain management
|
|Minimal pain anticipated
|-
|Potential complications
|
|
|}
== References ==
# Kampaktsis, P. N., Lebehn, M., & Wu, I. Y. (2021b). Mitral regurgitation in 2020: The 2020 focused update of the 2017 American College of Cardiology Expert Consensus Decision pathway on the management of mitral regurgitation. ''Journal of Cardiothoracic and Vascular Anesthesia'', ''35''(6), 1678–1690. <nowiki>https://doi.org/10.1053/j.jvca.2020.08.056</nowiki>
# Davidson, L. J., & Davidson, C. J. (2021). Transcatheter treatment of valvular heart disease. ''JAMA'', ''325''(24), 2480. <nowiki>https://doi.org/10.1001/jama.2021.2133</nowiki>
# Makkar RR, Chikwe J, Chakravarty T, et al. (2023). Transcatheter Mitral Valve Repair for Degenerative Mitral Regurgitation. ''JAMA 329(20),'' 1778–1788. doi:10.1001/jama.2023.7089
[[Category:Surgical procedures]]

Latest revision as of 13:12, 13 September 2025

Transcatheter mitral valve replacement
Anesthesia type

GA

Airway

ETT

Lines and access

2 PIVs, pre-induction arterial line

Monitors

Standard, intraoperative TEE

Primary anesthetic considerations
Preoperative

Symptoms of MR, functional capacity, dysphagia/prior gastrointestinal procedures (use of TEE intraoperatively)

Intraoperative

Hemodynamic management, continuous intraoperative TEE to guide device placement, anticoagulation

Postoperative
Article quality
Editor rating
Unrated
User likes
0

Transcatheter mitral valve replacement (TMVR) is a minimally invasive approach in which a prosthetic mitral valve is implanted through a transapical or transseptal approach to treat severe mitral valve disease in patients who are not suitable candidates for surgery or transcatheter edge-to-edge repair (TEER).

Transcatheter mitral valve edge-to-edge repair (TEER) is a minimally invasive approach to treat mitral regurgitation (MR) in patients who are at high or prohibitive surgical risk. The procedure involves percutaneous insertion of a clip device via the femoral vein, transseptal puncture, and deployment across the mitral valve leaflets under transesophageal echocardiographic (TEE) and fluoroscopic guidance. The clip approximates the anterior and posterior mitral leaflets at the site of regurgitation, reducing the severity of MR.

Main Types of TEER:

  • MitraClip (Abbott)
  • Pascal (Edwards)

Overview

Indications

  • Severe symptomatic primary (degenerative) mitral regurgitation
  • Moderate-to-severe or severe symptomatic secondary (functional) mitral regurgitation who remain symptomatic despite maximally tolerated guideline-directed medical therapy

Surgical procedure

  • Right femoral venous access
  • Transseptal puncture to access left atrium
  • Guide catheter and clip delivery system is navigated across mitral valve
  • Device positioned perpendicular to mitral leaflet coaptation, targeting area of maximal regurgitant jet, clip arms opened and advanced into left ventricle, then retracted to grasp both the anterior and posterior mitral leaflets
  • Confirm leaflet capture by TEE
  • Additional clips may be placed to optimize results
  • Guide catheter and clip delivery system removed
  • Achieve hemostasis at access site

Preoperative management

Patient evaluation

System Considerations
Airway
Neurologic
Cardiovascular Symptoms of mitral regurgitation, functional capacity
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

  • Type and screen

Operating room setup

  • Infusion and bolus vasopressors
    • Norepinephrine gtt
    • Phenylephrine, ephedrine, push dose epinephrine
  • Heparin and protamine

Patient preparation and premedication

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

  • Pre-induction arterial line
  • 2 peripheral IVs
    • Infusion line
    • Bolus line
  • Intraoperative transesophageal echocardiography (TEE)

Induction and airway management

Standard induction, endotracheal intubation

Positioning

Supine, arms tucked

Maintenance and surgical considerations

  • Maintaining hemodynamic stability
    • Avoiding hypotension and tachycardia, which can worsen mitral regurgitation
  • Continuous transesophageal echocardiography to guide device placement and assess mitral regurgitation reduction
  • Systemic heparinization to prevent thromboembolic events

Emergence

Postoperative management

Disposition

Cardiology floor with telemetry

Pain management

Minimal pain anticipated, often related to positioning or groin access site.

Potential complications

  • Bleeding
  • Pericardial tamponade
  • Vascular injury
  • Device specific complications
    • Single leaflet device attachment
    • Device embolization
    • Loss of leaflet insertion
  • Stroke
  • Myocardial infarction
  • Left ventricular thrombus formation

Procedure variants

Transcatheter mitral valve replacement (TMVR) Transcatheter edge-to-edge repair (TEER)
Unique considerations
Position Supine
Surgical time 2-3 hours
EBL Minimal
Postoperative disposition Floor with telemetry
Pain management Minimal pain anticipated
Potential complications

References

  1. Kampaktsis, P. N., Lebehn, M., & Wu, I. Y. (2021b). Mitral regurgitation in 2020: The 2020 focused update of the 2017 American College of Cardiology Expert Consensus Decision pathway on the management of mitral regurgitation. Journal of Cardiothoracic and Vascular Anesthesia, 35(6), 1678–1690. https://doi.org/10.1053/j.jvca.2020.08.056
  2. Davidson, L. J., & Davidson, C. J. (2021). Transcatheter treatment of valvular heart disease. JAMA, 325(24), 2480. https://doi.org/10.1001/jama.2021.2133
  3. Makkar RR, Chikwe J, Chakravarty T, et al. (2023). Transcatheter Mitral Valve Repair for Degenerative Mitral Regurgitation. JAMA 329(20), 1778–1788. doi:10.1001/jama.2023.7089

Top contributors: Katherine Lee and Tony Wang

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