DOCSLIB.ORG

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice Published online: 2019-08-17 1590 Theme Issue Article Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice Tobias Geisler1 Rezo Jorbenadze1 Aron-Frederik Popov2 Karin L. Mueller1 Dominik Rath1 Michal Droppa1 Juergen Schreieck1 Peter Seizer1 Robert F. Storey3 Steen D. Kristensen4 Andrea Rubboli5 Diana Gorog6,7 Daniel Aradi8,9 Dirk Sibbing10,11 Kurt Huber12,13 Meinrad Gawaz1 Jur Ten Berg14 1 Department of Cardiology and Angiology, University Hospital, Address for correspondence Tobias Geisler, MD, MHBA, Department Eberhard-Karls University of Tübingen, Tübingen, Germany of Cardiology and Angiology, University Hospital, Eberhard-Karls 2 Department of Thoracic and Cardiovascular Surgery, University University of Tübingen, Tübingen, Germany Medical Center Tübingen, Eberhard-Karls University of Tübingen, (e-mail: [email protected]; [email protected]). Tübingen, Germany 3 Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom 10Department of Cardiology, LMU München, Munich, Germany 4 Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark 11DZHK (German Centre for Cardiovascular Research), partner site 5 Division of Cardiology, Department of Cardiovascular Disease– Munich Heart Alliance, Munich, Germany AUSL Romagna, Ospedale S. Maria delle Croci, Ravenna, Italy 123rd Department of Medicine, Cardiology and Intensive Care 6 National Heart and Lung Institute, Imperial College London, Medicine, Wilhelminenhospital, Vienna, Austria London, United Kingdom 13Medical Faculty, Sigmund Freud University, Vienna, Austria 7 University of Hertfordshire, Hertfordshire, United Kingdom 14Department of Cardiology, St Antonius Hospital, Nieuwegein, 8 Heart Center Balatonfured, Balatonfured, Hungary The Netherlands 9 Heart and Vascular Center, Semmelweis University, Budapest, Hungary Thromb Haemost 2019;119:1590–1605. Abstract As the number of, and the indications for, structural heart interventions are increasing worldwide, the optimal secondary prevention to reduce device thrombosis is becoming more important. To date, most of the recommendations are empiric. The current review discusses mechanisms behind device-related thrombosis, the available evidence Keywords with regard to antithrombotic regimen after cardiac device implantation, as well as ► patent foramen ovale providing an algorithm for identification of risk factors for device thrombogenicity and ► left atrial appendage for management of device thrombosis after implantation of patent foramen ovale and ► MitraClip left atrial appendage occluders, MitraClips/transcatheter mitral valve replacement, ► left ventricular assist pacemaker leads, and left ventricular assist devices. Of note, the topic of antithrom- device botic therapy and thrombogenicity of prostheses in aortic position (transcatheter ► device-related aortic valve replacement, surgical, mechanical, and bioprostheses) is not part of the thrombosis present article and is discussed in detail in other contemporary focused articles. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Introduction Following device implantation, thrombotic events associated Michal Droppa’s ORCID is https://orcid.org/0000-0001-5807- with cardiac devices can be attributed to thrombosis that 7615. occurs either by direct contact activation on the device received © 2019 Georg Thieme Verlag KG DOI https://doi.org/ April 12, 2019 Stuttgart · New York 10.1055/s-0039-1694751. accepted after revision ISSN 0340-6245. June 21, 2019 Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and LVAD Geisler et al. 1591 surface (device thrombosis) or indirectly as a result of cardiac negatively charged hydrophilic surfaces that act indepen- thromboembolism provoked by changed hemodynamics and dently from blood flow velocity.1 Fibrinogen, fibronectin, flow characteristics after device implantation (device-relat- and von Willebrand factor (vWF) primarily adhere to the ed thrombosis [DRT]). In the following review, we shall surface of devices and lead to activation and adhesion of briefly discuss the mechanisms of device thrombosis and platelets. Negatively charged surfaces further activate factor DRT and give an overview of the clinical problems, epidemi- XII to factor XIIa, thus initiating the intrinsic pathway. Factor ological evidence, and management strategies of cardiac XIIa also induces complement activation leading to thrombin device thrombosis. A separate paragraph will provide an amplification. Leukocytes, in particular neutrophils, also update about the mechanisms of left ventricular assist device adhere to fibrinogen immobilized on the device surface via (LVAD) thrombosis and give guidance on treatment CD11b/CD18 (macrophage-1 antigen 1 [MAC-1]).2 Following strategies. adhesion and activation, platelets interact with leucocytes mainly via cross-linking of P-selectin with P-selectin glyco- α Mechanisms of Device Thrombosis protein ligand-1 and MAC-1 with glycoprotein 1b . Leuco- cyte degranulation contributes to a prothrombotic and Implantable devices usually contain a prothrombotic surface proinflammatory milieu by generating free radicals, releas- that lead to activation of the coagulation system by a ing interleukins and tumor necrosis factor α, and activating complex interplay between blood cells and plasma proteins. monocytes, leading to induction of tissue factor expression This process is characterized by enhanced adsorption of and consequent initiation of the coagulation cascade proteins, adhesion of platelets, leukocytes, and red blood (►Fig. 1). Attempts to reduce protein adsorption on the cells, activation of the extrinsic coagulation cascade leading device surface have been mainly driven by the reduction of to thrombin generation, and activation of the complement electrostatic and hydrophobic interactions between plasma system. Thrombogenicity is further enhanced by the under- proteins and the artificial surface. Synthetic and natural lying cardiac disease, particularly heart failure (HF), leading materials that hamper this process include polyethylene to disturbances in endothelial function and impaired blood oxide, phosphorylcholine, pyrolytic carbon, albumin, and flow and composition. Protein adsorption is caused by elastin-inspired protein polymers.1 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Fig. 1 Mechanism of contact activation on artificial surface leading to device thrombosis (figure was composed by using Adobe Stock vectors). DTI, direct thrombin inhibitor; IL, interleukin; MAC-1, macrophage-1 antigene; PSGL1, P-Selectin glycoprotein ligand-1; TF, tissue factors; TNF, tumor necrosis factor; VKA, vitamin k antagonists; vWF, von Willebrand factor. Thrombosis and Haemostasis Vol. 119 No. 10/2019 1592 Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and LVAD Geisler et al. Methods device and the time of follow-up was usually lower compared – with the medical arm in recent trials.5 7,9 It is difficult to We performed a systematic search regarding device throm- determine association with device thrombosis as, in some bosis and DRT and antithrombotic management after cardiac studies, different occluder devices were used7 and systematic device therapy in the international guidelines, including the transesophageal echocardiography (TOE) follow-up was per- guidelines and position papers of the European Society of formed in only few trials. Of note, there havebeen observations Cardiology (ESC)3,4 and the American Heart Association/ that stroke occurred even if there was no detection of device American Stroke Association. thrombosis nor device leakage,10,11 highlighting the impor- In addition, we searched for relevant ongoing clinical trials tance of careful risk assessment to first clarify the causality of in the registry of clinical trials (clinicaltrials.gov) using key- paradoxical embolism and second defining the residual stroke words “Mitral interventions,”“left atrial appendage (LAA) risk after PFO occluder. occlusion,”“antithrombotic treatment,” and “patent foramen PFO closure device thrombosis is a rare event and has been ovale/PFO.” A review of current literature was performed using described in ranges from 0.4 to 1.2% depending on the type of the search terms “device related thrombosis,”“antithrombotic occluder and duration of follow-up (►Fig. 2).12,13 In a system- therapy after cardiac devices,”“thrombolytic therapy for device atic series of 620 patients treated with the AMPLATZER thrombosis,”“patent foramen ovale / PFO,”“cardiac occluder,” PFO occluder for secondary prevention of paradoxical embo- “LAA,”“Amplatzer Cardiac Plug and thrombosis,”“Amplatzer lism, 6-month follow-up revealed only two cases showing small Amulet and thrombosis,”“Watchman and thrombosis,”“pace- thrombi on the atrial disk.14 Although thrombi at the right atrial maker related thrombosis,”“ICD related thrombosis,” and disc have been usually reported, there are single reports of “LVAD thrombosis” in pubmed.gov. organized thrombi at the left atrial disc (example of echocar- diographic finding in ►Fig. 3C and ref. 15). It is a matter of debate Risk Factors for Patent Foramen Ovale whether PFO occluder thrombosis is related to the device itself ClosureDeviceThrombosis or rather due to a hypercoagulable state as a consequence of alteration in hemodynamics
Load more

Recommended publications
  • Stent Technology Takes Two Steps Forward
    Inside This Issue Heart and Vascular Update Hybrid operating room, provides information to PRESORTED HEART and VASCULAR healthcare providers on the latest FIRST CLASS MAIL a regional first in cardiovascular medicine and surgery U.S. POSTAGE at The Christ Hospital. PAID Stent technology takes CINCINNATI, OH Heart and Vascular Update PERMIT #5489 two steps forward Editorial Board 2139 Auburn Avenue | Cincinnati, Ohio 45219 Stent technology Dean J. Kereiakes, MD, FDA advisory panel: Medical Director SPRING 2013 The Christ Hospital Heart and Vascular Center Update MitraClip could serve as takes two steps forward Carl and Edyth Lindner Research Center an alternative treatment Ian Sarembock, MD, Executive Medical Director for reducing mitral Resorbable Absorb scaffold and flexible Absorb takes bioabsorbability to next level The Christ Hospital Heart and Vascular Service Line regurgitation For the past two decades, incremental improvements in stent Mike Keating Synergy stent expected to improve technology have improved outcomes for hundreds of thousands of President and CEO outcomes in coronary artery disease people with coronary artery blockages. These devices have evolved Michael W. Schwebler from short, bare-metal mesh tubes that could be deployed only The Carl and Eydth Lindner Research Center at The Christ Hospital is Executive Director in the largest coronary vessels to a variety of thinner, longer stents The Christ Hospital Heart and Vascular Service Line leading two major clinical trials that will significantly advance stent coated with
    [Show full text]
  • Program PDF Saturday, March 28, 2020 Updated: 02-14-20
    Program PDF Saturday, March 28, 2020 Updated: 02-14-20 Special ‐ Events and Meetings Congenital Heart Disease ‐ Scientific Session #5002 Session #602 Fellowship Administrators in Cardiovascular Education and ACHD Cases That Stumped Me Training Meeting, Day 2 Saturday, March 28, 2020, 8:00 a.m. ‐ 9:30 a.m. Saturday, March 28, 2020, 7:30 a.m. ‐ 5:30 p.m. Room S105b Marriott Marquis Chicago, Great Lakes Ballroom A CME Hours: 1.5 / CNE Hours: CME Hours: / CNE Hours: Co‐Chair: C. Huie Lin 7:30 a.m. Co‐Chair: Karen K. Stout Fellowship Administrators in Cardiovascular Education and Training Meeting, Day 2 8:00 a.m. LTGA, Severe AV Valve Regurgitation, Moderately Reduced EF, And Atrial Acute and Stable Ischemic Heart Disease ‐ Scientific Arrhythmia Session #601 Elizabeth Grier Treating Patients With STEMI: What They Didn't Teach You in Dallas, TX Fellowship! Saturday, March 28, 2020, 8:00 a.m. ‐ 9:30 a.m. 8:05 a.m. Room S505a ARS Questions (Pre‐Panel Discussion) CME Hours: 1.5 / CNE Hours: Elizabeth Grier Dallas, TX Co‐Chair: Frederick G. Kushner Co‐Chair: Alexandra J. Lansky 8:07 a.m. Panelist: Alvaro Avezum Panel Discussion: LTGA With AVVR And Reduced EF Panelist: William W. O'Neill Panelist: Jennifer Tremmel Panelist: Jonathan Nathan Menachem Panelist: Joseph A. Dearani 8:00 a.m. Panelist: Michelle Gurvitz Case of a Young Women With STEMI Panelist: David Bradley Jasjit Bhinder Valhalla, NY 8:27 a.m. ARS Questions (Post‐Panel Discussion) 8:05 a.m. Elizabeth Grier Young Women With STEMI: Something Doesn't Make Sense...
    [Show full text]
  • Surgical Management of Transcatheter Heart Valves
    Corporate Medical Policy Surgical Management of Transcatheter Heart Valves File Name: surgica l_management_of_transcatheter_heart_valves Origination: 1/2011 Last CAP Review: 6/2021 Next CAP Review: 6/2022 Last Review: 6/2021 Description of Procedure or Service As the proportion of older adults increases in the U.S. population, the incidence of degenerative heart valve disease also increases. Aortic stenosis and mitra l regurgita tion are the most common valvular disorders in adults aged 70 years and older. For patients with severe valve disease, heart valve repair or replacement involving open heart surgery can improve functional status and qua lity of life. A variety of conventional mechanical and bioprosthetic heart valves are readily available. However, some individuals, due to advanced age or co-morbidities, are considered too high risk for open heart surgery. Alternatives to the open heart approach to heart valve replacement are currently being explored. Transcatheter heart valve replacement and repair are relatively new interventional procedures involving the insertion of an artificial heart valve or repair device using a catheter, rather than through open heart surgery, or surgical valve replacement (SAVR). The point of entry is typically either the femoral vein (antegrade) or femora l artery (retrograde), or directly through the myocardium via the apical region of the heart. For pulmonic and aortic valve replacement surgery, an expandable prosthetic heart valve is crimped onto a catheter and then delivered and deployed at the site of the diseased native valve. For valve repair, a small device is delivered by catheter to the mitral valve where the faulty leaflets are clipped together to reduce regurgitation.
    [Show full text]
  • Highlights from the Latest Articles in Ablation and Endovascular Valve Repair
    NEWS & VIEWS Research Highlights Highlights from the latest articles in ablation and endovascular valve repair Torsten Konrad*1 Relationship between electrical & Thomas Rostock1 1II Medical Clinic, Department of Electrophysiology, University Medical Center, Johannes pulmonary vein reconnection and Gutenberg-University Mainz, Langenbeckstraße 1, D-55131 Mainz, Germany *Author for correspondence: Tel.: +49 613 117 7218 contact force during initial pulmonary Fax: +49 613 117 5534 [email protected] vein isolation Financial & competing interests disclosure All PVs were initially successfully isolated The authors have no relevant affiliations or financial Evaluation of: Neuzil P, Reddy V, with this technique. In almost half of the involvement with any organization or entity with a Kautzner J et al. Electrical patients, a deflectable sheath was used financial interest in or financial conflict with the reconnection after pulmonary vein during the initial ablation procedure subject matter or materials discussed in the manu- isolation is contingent on contact (mean CF was not different when using script. This includes employment, consultancies, force during initial treatment: a deflectable or conventional sheath). honoraria, stock ownership or options, expert testi- results from the EFFICAS I study. In general, CF was higher in the right mony, grants or patents received or pending, or Circ. Arrhythm. Electrophysiol. 6, PVs than the left PVs. Lowest CFs were royalties. 327–333 (2013). observed during ablation of the left PVs No writing assistance was utilized in the at the anterior superior and anterior infe- production of this manuscript. Pulmonary vein (PV) isolation is the rior aspect of the PVs. The highest CFs most common and effective interven- were documented at the anterior inferior tional treatment for paroxysmal atrial aspect of the right PVs.
    [Show full text]
  • Development of a Simultaneous Cryo-Anchoring and Radiofrequency Ablation Catheter for Percutaneous Treatment of Mitral Valve Prolapse
    DEVELOPMENT OF A SIMULTANEOUS CRYO-ANCHORING AND RADIOFREQUENCY ABLATION CATHETER FOR PERCUTANEOUS TREATMENT OF MITRAL VALVE PROLAPSE By Steven Michael Boronyak Thesis Submitted to the Faculty of the Graduate School of Vanderbilt University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE in Biomedical Engineering May, 2012 Nashville, Tennessee Approved: W. David Merryman, Ph.D. Robert L. Galloway, Ph.D. ACKNOWLEDGEMENTS First, I would like to thank Dr. David Merryman for his guidance and support throughout the last two years. Second, I would like to thank my fellow lab members for making work more fun than it needs to be. Third, this work was funded by the Wallace H. Coulter Foundation, and I thank them, too. Cheers. ii TABLE OF CONTENTS Page ACKNOWLEDGEMENTS ................................................................................................ ii LIST OF FIGURES .......................................................................................................... v I. INTRODUCTION ......................................................................................................... 1 Background.......................................................................................................... 1 Mitral Valve Anatomy and Function ......................................................... 1 Mitral Regurgitation and Mitral Valve Prolapse ........................................ 2 MVP Due to Degenerative MR ................................................................ 3 Repair of the
    [Show full text]
  • Download Des Gedruckten Programms (PDF
    79. Jahrestagung der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e.V. 79th Annual Meeting of the German Cardiac Society Die Kardiomyopathien The Cardiomyopathies Tagungspräsident / President of the Congress Prof. Dr. Hugo A. Katus, Heidelberg Präsident der Gesellschaft / President of the Society Prof. Dr. Georg Ertl, Würzburg Geschäftsführer der Gesellschaft / Managing Director Dipl.-Math. Konstantinos Papoutsis, Düsseldorf Änderungen vorbehalten. Aktualisierungen nach Drucklegung aufrufbar unter: http://ft2013.dgk.org Drucklegung: 20.02.2013 Deutsche Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e.V. 79. Jahrestagung 2013, Mannheim Vorwort • Vorstand • Kommissionen 6 - 9 Projekt- und Arbeitsgruppen • Arbeitsgemeinschaften 10 - 16 Ehrungen und Preise 18 Stipendien und Preise 19 - 20 Poster- und Abstractpreise 21 Sonstige Preise 21 Tagungsort/Öffnungszeiten • Allgemeine Informationen 22 - 27 Hinweise für Referenten • Hinweise für Posterreferenten 28 - 31 Ankündigungen • Weiter- und Fortbildungs-Akademie „Kardiologie“ 32 - 40 Mittwoch, 3. April 2013 Raumplan - Wissenschaftliches Programm 42 - 111 Donnerstag, 4. April 2013, vormittags Raumplan - Wissenschaftliches Programm 114 - 188 Donnerstag, 4. April 2013, nachmittags Wissenschaftliches Programm 190 - 255 Freitag, 5. April 2013, vormittags Raumplan - Wissenschaftliches Programm 258 - 338 Freitag, 5. April 2013, nachmittags Wissenschaftliches Programm 340 - 398 Samstag, 6. April 2013, vormittags Raumplan - Wissenschaftliches Programm 400 - 465 Samstag,
    [Show full text]
  • Selecting Candidates for Transcatheter Mitral Valve Repair
    • INNOVATIONS Key Points Selecting Candidates for • Mitral valve regurgitation, or leaky mitral valve, is a common valve disorder Transcatheter Mitral Valve Repair in which the leaflets of the mitral valve fail to seal effectively, resulting in Annapoorna S. Kini, MD Samin K. Sharma, MD some blood flowing back in the left atrium every time Mitral valve regurgitation is a common valve disorder The EVEREST (Endovascular Valve Edge-to- the left ventricle contracts. that causes blood to leak backward through the Edge Repair Study) II Trial was a randomized study This condition has been mitral valve and into the left atrium as the heart comparing the transcatheter approach using traditionally addressed muscle contracts. Mitral regurgitation can originate MitraClip®—a tiny cobalt chromium clip that sutures with open heart surgery. from degenerative or structural defects due to the anterior and posterior mitral valve leaflets—with aging, infection, or congenital anomalies. In contrast, surgery in patients with moderate to severe mitral • We use the latest imaging functional mitral regurgitation occurs when coronary regurgitation who are candidates for either procedure. techniques both to ensure artery disease or events such as a heart attack change that each patient is a good After five years, the study has demonstrated that the size and shape of the heart muscle, preventing candidate for the procedure, MitraClip was associated with a similar risk of death the mitral valve from opening and closing properly. In and to monitor their progress compared with mitral valve surgery after excluding people with moderate to severe mitral regurgitation, once the device is implanted. patients who required surgery within six months.
    [Show full text]
  • Medicare National Coverage Determinations Manual, Part 1
    Medicare National Coverage Determinations Manual Chapter 1, Part 1 (Sections 10 – 80.12) Coverage Determinations Table of Contents (Rev. 10838, 06-08-21) Transmittals for Chapter 1, Part 1 Foreword - Purpose for National Coverage Determinations (NCD) Manual 10 - Anesthesia and Pain Management 10.1 - Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery 10.2 - Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post- Operative Pain 10.3 - Inpatient Hospital Pain Rehabilitation Programs 10.4 - Outpatient Hospital Pain Rehabilitation Programs 10.5 - Autogenous Epidural Blood Graft 10.6 - Anesthesia in Cardiac Pacemaker Surgery 20 - Cardiovascular System 20.1 - Vertebral Artery Surgery 20.2 - Extracranial - Intracranial (EC-IC) Arterial Bypass Surgery 20.3 - Thoracic Duct Drainage (TDD) in Renal Transplants 20.4 – Implantable Cardioverter Defibrillators (ICDs) 20.5 - Extracorporeal Immunoadsorption (ECI) Using Protein A Columns 20.6 - Transmyocardial Revascularization (TMR) 20.7 - Percutaneous Transluminal Angioplasty (PTA) (Various Effective Dates Below) 20.8 - Cardiac Pacemakers (Various Effective Dates Below) 20.8.1 - Cardiac Pacemaker Evaluation Services 20.8.1.1 - Transtelephonic Monitoring of Cardiac Pacemakers 20.8.2 - Self-Contained Pacemaker Monitors 20.8.3 – Single Chamber and Dual Chamber Permanent Cardiac Pacemakers 20.8.4 Leadless Pacemakers 20.9 - Artificial Hearts And Related Devices – (Various Effective Dates Below) 20.9.1 - Ventricular Assist Devices (Various Effective Dates Below) 20.10 - Cardiac
    [Show full text]
  • Review of Diagnostic and Therapeutic Approach to Canine Myxomatous Mitral Valve Disease
    veterinary sciences Review Review of Diagnostic and Therapeutic Approach to Canine Myxomatous Mitral Valve Disease Giulio Menciotti * ID and Michele Borgarelli Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, 205 Duck Pond Dr., Blacksburg, VA 24061, USA; [email protected] * Correspondence: [email protected]; Tel.: +1-540-2314-621 Academic Editors: Sonja Fonfara and Lynne O’Sullivan Received: 23 June 2017; Accepted: 20 September 2017; Published: 26 September 2017 Abstract: The most common heart disease that affects dogs is myxomatous mitral valve disease. In this article, we review the current diagnostic and therapeutic approaches to this disease, and we also present some of the latest technological advancements in this field. Keywords: dogs; heart; echocardiography; mitral repair 1. Introduction Among canine cardiac diseases, myxomatous mitral valve disease (MMVD) represents, by far, the most common. In general, the disease is more prevalent in small breeds than in large breeds, and some small breeds are reported to have an incidence close to 100% over a dog’s lifetime [1,2]. However, large breed dogs can be affected as well [3,4]. A heritable, genetically-determined component for the disease can be implied by the strong predilection for small breeds in general, and particularly for certain breeds (i.e., Cavalier King Charles Spaniels, Dachshund), in which the heritability of disease status and severity has been demonstrated [5–7]. However, the etiology of the myxomatous process is still unknown and under investigation. Some experimental evidence seems to support a possible role of the serotonin signaling pathway triggered by altered mechanical stimuli in the disease development [8–12].
    [Show full text]
  • Mitraclip Cases
    MitraClip Cases Sunil Mankad, MD, FACC, FCCP, FASE Associate Professor of Medicine Mayo Clinic College of Medicine Director, Transesophageal Echocardiography Associate Director, Cardiology Fellowship Mayo Clinic, Rochester, MN ACC Governor, Minnesota [email protected] @MDMankad DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None Case 1 • 86 year old female • Acute onset dyspnea from pulmonary edema • History of prior CABG • CKD (creatinine 2.0 mg/dl) • Paroxysmal atrial fibrillation • Physical exam – 3/6 holosystolic murmur • TTE – Flail MV with severe mitral regurgitation – LV EF 60% CXR EKG • Catheterization: Patent Grafts TEE TEE: Flail MV Posterior Leaflet A1-P1/lateral portion of P2 TEE A2-medial portion P2 A3-P3 TEE: Commissural View TEE TEE 3D TEE: View from LA Mitral Valve • Mean Gradient 5 mmHg at HR of 88 BPM • Valve area >4.0 cm2 Heart Team Discussion • CV Surgery, Valve/Imaging Specialist, and Structural Interventionalist → Decision made to proceed with MitraClip Procedural TEE: Flail P2 (Lateral Portion) Transeptal Puncture Sheath in Left Atrium MitraClip Device in Left Atrium MitraClip Device Toward MV Heading Toward Valve Importance of Clip Orientation Wrong Correct Grasping MV MV Grasped MV Grasped Final Result: Mild MR Mean Gradient 5 at HR 77 BPM Final 3D Images 45 mmHg Pre-clip Post-clip 15 mmHg Left Atrial “V” wave Tracings Atrial Septum: Small ASD Pre-discharge TTE: Mild MR → Mean Gradient 3 at HR 59 BPM Outcome • Patient discharged home 4 days post- procedure • Dyspnea markedly improved • Continues
    [Show full text]
  • Mitral Valve Disease
    ©2010 David Stultz, MD MitralMitral valvevalve diseasedisease DavidDavid Stultz,Stultz, MD,MD, FACCFACC SouthwestSouthwest Cardiology,Cardiology, Inc.Inc. SeptemberSeptember 28,28, 20102010 ©2010 David Stultz, MD ObjectivesObjectives IdentifyIdentify thethe principleprinciple causecause ofof mitralmitral stenosisstenosis NameName severalseveral mechanismsmechanisms ofof mitralmitral regurgitationregurgitation IdentifyIdentify howhow oftenoften mitralmitral regurgitationregurgitation shouldshould bebe followedfollowed byby echocardiogramechocardiogram ©2010 David Stultz, MD ThisThis ConferenceConference isis anan OverviewOverview ManyMany aspectsaspects cannotcannot bebe coveredcovered inin aa 11 hourhour conferenceconference ThisThis isis meantmeant toto serveserve asas aa frameworkframework forfor furtherfurther knowledgeknowledge ©2010 David Stultz, MD OutlineOutline ofof conferenceconference MitralMitral StenosisStenosis MitralMitral regurgitationregurgitation MitralMitral valvevalve prolapseprolapse SurgicalSurgical andand endovascularendovascular repairrepair ©2010 David Stultz, MD Libby P, Bonow RO, Mann DL, Zipes DP. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, Saunders, 2007. ©2010 David Stultz, MD SurgicalSurgical AnatomyAnatomy Fedak PW, McCarthy PM, Bonow RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008 Feb 19;117(7):963- 74. ©2010 David Stultz, MD MitralMitral StenosisStenosis NarrowingNarrowing ofof thethe mitralmitral valvevalve orificeorifice RestrictsRestricts
    [Show full text]
  • Mitraclip™ NT Clip Delivery System Mitraclip™ NT System Instructions
    MitraClip™ NT Clip Delivery System MitraClip™ NT System Clip Delivery System Ref No. CDS0501 Steerable Guide Catheter Ref No. SGC0101/Ref No. SGC0301 ™ MitraClip™ System Accessories Stabilizer Ref No. SZR01ST Lift Ref No. LFT01ST Support Plate Ref No. PLT01ST Instructions for Use WARNING: Read all instructions carefully. Failure to follow these instructions, warnings and precautions may lead to device damage or patient injury. Use of the MitraClip™ NT should be restricted to those physicians trained to perform invasive endovascular and transseptal procedures and to those physicians trained in the proper use of the system. NOTE: The MitraClip NT Clip Delivery System Ref No. CDS0501 is fully compatible with Steerable Guide Catheter Ref No. SGC0101 and Ref No. SGC0301. The procedure step-by-step instructions for the use of the Steerable guide have not changed. Please refer to the instructions for use for Ref No. SGC0101 to obtain information on how Ref No. SGC0101 is supplied. Table of Contents 1.0 INDICATION FOR USE 2.0 CONTRAINDICATIONS 3.0 WARNINGS 4.0 PRECAUTIONS 5.0 SPECIAL PATIENT POPULATIONS 6.0 POTENTIAL COMPLICATIONS AND ADVERSE EVENTS 7.0 PATIENT COUNSELING 8.0 HOW SUPPLIED 8.1 Contents 8.2 Sterile 8.3 Non-Sterile 9.0 STORAGE 10.0 MITRACLIP™ NT SYSTEM DIMENSIONS 11.0 GLOSSARY OF ACRONYMS 12.0 DEVICE DESCRIPTION 12.1 MRI Safety Information 12.2 MitraClip™ System Accessories Overview 13.0 REQUIRED ACCESSORIES 14.0 ADDITIONAL REQUIRED EQUIPMENT NOT INCLUDED EL2106481 (2019-03-04) Page 1 of 85 15.0 OVERVIEW OF CLINICAL STUDIES 15.1
    [Show full text]