Echocardiographic guidance and assessment of percutaneous repair for mitral regurgitation with the Evalve MitraClip: lessons learned from EVEREST I.
OBJECTIVE
Percutaneous mitral repair is rapidly developing as an alternative to cardiac surgery in select patients. The Evalve percutaneous E2E system uses the MitraClip to replicate the surgical suture-based approach. This procedure requires real-time echocardiographic guidance in a unique and significant collaboration between echocardiographer and interventionalist. transesophageal echocardiography (TEE) is used as the primary imaging modality to guide this procedure and is essential to its success.


METHODS
In EVEREST I, the US multicenter phase I safety and feasibility trial, 47 patients with 3 or 4+ mitral regurgitation (MR) were enrolled. The trial involved a standardized echocardiographic imaging protocol with a standardized anatomic-based vocabulary, predetermined standard TEE views, preprocedural strategy meetings, and display of echocardiographic aids to optimize communication and procedural efficiency during placement of the clip.


RESULTS
TEE guidance facilitated the creation of a double-orifice mitral valve in all 47 patients enrolled (100%), and 40 patients were discharged with 1 or more clips (85%). At discharge, successful placement of a clip and <or= 2+ MR was present in 34 patients (74%). The standardized approach contributed to a reduction in the time to perform the procedure over the course of the trial at both initial and new sites.


CONCLUSIONS
TEE is essential to the guidance of percutaneous MitraClip E2E repair. A streamlined approach to echocardiographic guidance, using predetermined standardized views, a common anatomic-based vocabulary, preprocedural strategy meetings, and a display of echocardiographic aids in the catheterization laboratory shortens the procedure time and allows for efficient percutaneous repair.
Silvestry
Frank E
FE
Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. Fsilvest@mail.med.upenn.edu
Rodriguez
L Leonardo
LL
Herrmann
Howard C
HC
Rohatgi
Sameer
S
Weiss
Stuart J
SJ
Stewart
William J
WJ
Homma
Shunichi
S
Goyal
Neil
N
Pulerwitz
Todd
T
Zunamon
Alan
A
Hamilton
Andrew
A
Merlino
John
J
Martin
Randolph
R
Krabill
Kimberly
K
Block
Peter C
PC
Whitlow
Pat
P
Tuzcu
E Murat
EM
Kapadia
Samir
S
Gray
William A
WA
Reisman
Mark
M
Wasserman
Hal
H
Schwartz
Allan
A
Foster
Elyse
E
Feldman
Ted
T
Wiegers
Susan E
SE
D000368:Aged; D001783:Blood Flow Velocity / Q000502:physiology; D006328:Cardiac Catheterization; D006348:Cardiac Surgical Procedures / Q000295:instrumentation*; D018618:Echocardiography, Doppler, Color / Q000379:methods*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D004867:Equipment Design; D006801:Humans; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D012720:Severity of Illness Index; D016896:Treatment Outcome