Transcatheter mitral valve replacement

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
Intraoperative
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

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

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