As the MitraClip procedure becomes more available to hospitals it is imperative that sonographers understand the goals of the transthoracic echocardiogram prior to the MitraClip procedure. In this blog we will review the 7 components for a complete MitraClip echo protocol.. In past blogs we have outlined how to asses and quantify mitral valve pathology and mitral regurgitation, including step by step guides for PISA and other MR quantification methods. If you need a refresher, check out past articles here:
Abbott states the indication for use of the MitraClip as follows: “The MitraClip Clip Delivery System is indicated for the percutaneous reduction of significant symptomatic mitral regurgitation (MR ≥ 3+) due to primary abnormality of the mitral apparatus [degenerative MR] in patients who have been determined to be at prohibitive risk for mitral valve surgery by a heart team, which includes a cardiac surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease, and in whom existing comorbidities would not preclude the expected benefit from reduction of the mitral regurgitation.”
For those less familiar with the MitraClip it is a
The seven components of a complete echo protocol are:
Because the MitraClip is indicated for the reduction of significant mitral regurgitation for patients with degenerative [primary] MR one of the main goals of the echocardiogram for potential MitraClip patients is to identify if the valve has degenerative or functional disease. Degenerative MR is also called Organic and/or primary MR. This basically means that the valve itself is the cause of the regurgitation. With degenerative MR the regurgitation is due to abnormalities of the mitral leaflets versus abnormalities caused by the left ventricle. The MitraClip is indicated for severe degenerative disease. Some examples of severe degenerative MR include:
Evaluating the mitral valve includes documenting how calcified the valve is. The MitraClip is not able to be deployed on severely calcified leaflets. Even small areas of calcification Look for small areas of calcification that may be missed
When reporting on mitral valve disease remember to identify the leaflet and the scallop. Here is a cheat sheet to help you remember which scallop is visualized in each of the major echo views:
The MitraClip is used to reduce significant MR. All patients that may be a candidate for the MitraClip procedure must have a complete quantitative assessment of the mitral valve to include PISA. Review A complete guide to performing MR PISA. Markers for severe MR include both Doppler quantification and other markers such as an enlarged left ventricle, moderately to severely enlarged left atrium and pulmonary hypertension.
Flow reversal in the pulmonary veins has a greater than 85% probability of severe MR. Always evaluate the pulmonary veins for flow reversal when performing a MitraClip echo scanning protocol.
Because the MitraClip will decrease the area of the mitral valve it is essential to obtain a pre-clip mitral valve area (MVA). A complete assessment of the MVA will include obtaining CW through the MV and obtaining a mean pressure gradient and calculating the MVA. The P1/2t formula is the recommended method for calculating the MVA.
It’s necessary to evaluate the size and function of the left ventricle. Focus on quantitative rather than qualitative (eye-balling). The best practice is to perform the biplane Simpsons measurement to obtain an LV volume and ejection fraction.
7. Rule Out Other Valvular Disease
Other Valvular Disease
Be sure to perform a complete echocardiogram and include the following: