A hybrid technique for treatment of commissural primary mitral regurgitation

Transcatheter Mitral Valve Repair-Beyond the EVEREST and COAPT Criteria

Transcatheter mitral valve repair (TMVr) has emerged as a safe and effective alternative to conventional surgery in patients with primary and secondary mitral regurgitation, especially those at high surgical risk. This review summarises alternative indications for TMVr outside of the traditional criteria derived from the major randomised trials and focusses on less common mitral valve anatomies such as commissural prolapse and bileaflet prolapse, patients with mitral annuloplasty rings, as well as acutely unwell patients with papillary muscle rupture and/or cardiogenic shock. Specific technical challenges involved in treating such patient groups are summarised and described.

Advanced Steering Maneuvers for Special Situations in Mitral Valve Transcatheter Edge-to-edge Repair

The use of transcatheter percutaneous edge-to-edge mitral valve repair with the MitraClip (Abbott) for the treatment of mitral regurgitation has rapidly expanded since it received Food and Drug Administration approval. Currently, patients with more complex mitral valve anatomies are undergoing this procedure with progressively improving clinical outcomes. This review focuses on the advanced steering maneuvers needed for the technical success of the MitraClip procedure and discusses several scenarios where such advanced steering maneuvers may be needed. These include an anterior transseptal puncture, low or high transseptal puncture with unfavorable transseptal height to mitral valve, large gap height, patients with mitral regurgitation due to dehiscence of a prior mitral valve annuloplasty ring, placing multiple/adjacent MitraClips, or redo edge-to-edge mitral valve repair. Knowledge and mastery of such advanced steering maneuvering techniques can allow operators to complete the procedure successfully with low rate of complications even in difficult scenarios.

Transcatheter Mitral Valve Edge-to-Edge Repair for Commissure Prolapse Successfully Guided by Stitch Artifact Technique

Illustration of the "Stitch Artifact Technique". (A) By conducting 2-beat image acquisition without stopping the ventilation, we can create stitch artifact on the 3D image intentionally. (B) This stitch artifact on 3D image indicates the exact position and angle of 2D cut-plane image which we visualized just before showing 3D-image.

Conceiving MitraClip as a tool: percutaneous edge-to-edge repair in complex mitral valve anatomies

Improvements in procedural technique and intra-procedural imaging have progressively expanded the indications of percutaneous edge-to-edge technique. To date in higher volume centres and by experienced operators MitraClip is used for the treatment of complex anatomies and challenging cases in high risk-inoperable patients. This progressive step is superimposable to what observed in surgery for edge-to-edge surgery (Alfieri's technique). Moreover, the results of clinical studies on the treatment of patients with high surgical risk and functional mitral insufficiency have confirmed that the main goal to be achieved for improving clinical outcomes of patients with severe mitral regurgitation (MR) is the reduction of MR itself. The MitraClip should therefore be considered as a tool to achieve this goal in addition to medical therapy. Nowadays, evaluation of patient's candidacy to MitraClip procedure, discussed in local Heart Team, must take into account not only the clinical features of patients but even the experience of the operators and the volume of the centre, which are mostly related to the probability to achieve good procedural results. This 'relative feasibility' of challenges cases by experienced operators should always been taken into account in selecting patients for MitraClip. Here, we present a review of the literature available on the treatment of complex and challenging lesions.

Cardiac prostheses-related hemolytic anemia

Hemolysis is an unintended sequel of temporary or permanent intracardiac devices. However, limited data exist on the characteristics and treatment of hemolysis in patients with cardiac prostheses. This entity, albeit uncommon, often poses significant diagnostic and management challenges to the clinical cardiologist. In this article, we aim to provide a contemporary overview of the incidence, mechanisms, diagnosis, and management of cardiac prosthesis‐related hemolysis.