Difference between revisions of "Transcatheter mitral valve replacement"
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| lines_access = 2 PIVs, pre-induction arterial line | | lines_access = 2 PIVs, pre-induction arterial line | ||
| monitors = Standard, intraoperative TEE | | monitors = Standard, intraoperative TEE | ||
| considerations_preoperative = | | considerations_preoperative = Symptoms of MR, functional capacity, dysphagia/prior gastrointestinal procedures (use of TEE intraoperatively) | ||
| considerations_intraoperative = | | considerations_intraoperative = Hemodynamic management, continuous intraoperative TEE to guide device placement, anticoagulation | ||
| considerations_postoperative = | | considerations_postoperative = | ||
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== References == | == 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]] | [[Category:Surgical procedures]] | ||
Latest revision as of 13:12, 13 September 2025
| 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 | |
| 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
- 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
- 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
- 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
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