Trans-catheter mitral (or tricuspid) edge-to-edge repair for severe mitral regurgitation (MR) or tricuspid regurgitation (TR) involves the insertion of a catheter through the femoral vein across the interatrial septum (IAS). Typically, between one and three clips are deployed during the procedure. All patients will have been discussed at the mitral multidisciplinary team (MDT) meeting and will have been deemed unsuitable for conventional cardiac surgery. These patients are usually elderly and frail, often with multiple comorbidities. Procedures are conducted in catheter labs 1 or 2 and require general anesthesia (GA) and transesophageal echocardiography (TOE).
Procedural complications include:
o Vascular injury
o Cardiac tamponade
o ASD
o Single leaflet device detachment
o Device embolization
o Air embolization
o Oesophageal injury/perforation
Lines:
o 14G IV
o Invasive arterial monitoring
o COETT
o CVC not usually required – the cardiologists can offer you the side arm of the femoral venous sheath if necessary
Cefuroxime 1.5g is administered for antibiotic prophylaxis, alongside standard induction agents and general anesthesia maintenance. The aim is to maintain hemodynamics that are reflective of a normal state to allow for an accurate assessment of the mitral valve. It is important to use judicious fluids, avoid bradycardia, and maintain normotension.
TOE manipulation throughout procedure:
o Need to obtund pharyngeal reflexes (opioids/neuromuscular block)
o Avoid coughing and gagging especially when device engaged with mitral valve
Heparin is administered with the goal of achieving an activated clotting time (ACT) greater than 300 seconds. Following the procedure, patients are extubated and subsequently recover in the catheter lab recovery area, where the arterial line is removed. Most patients experience minimal postoperative pain, with the exception of a sore throat. They are then transferred back to the cardiac ward, as admission to the ICU or HDU is only necessary in the event of major complications.
Southampton Cardiac Anaesthesia 