Unlocking and Removing MitraClip Technique in Mitral Valve Re-Repair Surgery

T. Lysyy¹, M. Gerdisch^2
1Washington University in St. Louis, St. Louis, Missouri ²Cardiac Surgery Associates, Indianapolis, Indiana

Please explain the educational or technical point that this video addresses.: This video addresses a crucial surgical technique for unlocking and removing the MitraClip device during mitral valve re-repair surgeries. As the use of transcatheter edge-to-edge repair (TEER) with MitraClip becomes more widespread, there is an increasing need for surgical intervention following unsuccessful TEER procedures. These surgeries are high-risk and often necessitate mitral valve replacement due to the difficulties in removing the MitraClip without damaging the valve.
The video explains a precise method for MitraClip removal that minimizes trauma to the mitral valve leaflets and chordae, which are essential for successful re-repair. The technique involves stabilizing the MitraClip, threading a suture through the locking mechanism, and carefully opening the clip arms to release the valve leaflets without causing damage. This method ensures that the leaflets and marginal chordae remain intact, facilitating a more effective and durable mitral valve re-repair.
Through a detailed clinical scenario, the video demonstrates the procedure on a patient with severe mitral regurgitation and a history of unsuccessful MitraClip implantation. It covers the surgical steps, including the use of various instruments to remove the MitraClip, the application of annuloplasty rings, and the repair of additional valve defects. The video emphasizes the importance of mastering this technique for mitral valve surgeons to address the growing demand for surgical reinterventions in patients with failed TEER, ultimately improving patient outcomes.

Please provide a 250 word summary of the surgical video being submitted.: The patient is a 69-year-old male with chronic kidney disease, myocardial infarction, and 10 years longstanding persistent atrial fibrillation (AF), two years s/p MitraClip. Echocardiography showed severe mitral regurgitation (MR), moderate tricuspid insufficiency, left ventricular end-diastolic dimension (EDD) 7cm, ejection fraction (EF) 35%, and left atrium (LA) 6.9cm. Cardiac index was 1.4 l/min/m2 with NYHA class IV. After diuresis with IABP, MV re-repair, tricuspid valve repair, biatrial Cox-Maze IV, and LIMA to LAD for 70% lesion were performed.
Cardiopulmonary bypass was initiated via sternotomy with bicaval cannulation. Del Nido cardioplegia was administered. The left pulmonary veins and atrial appendage lesions were performed, and an AtriClip applied. After LIMA-LAD, the interatrial groove was opened, and the left Maze was completed.
MitraClip was fixed to A2-P2. Mixter Right Angled forceps stabilized the MitraClip below the leaflets. After threading a 3-0 polypropylene through the loop of the locking mechanism, moderate traction opened the clip arms. After removing tissue from the clip grippers, Schnidt Tonsil Hemostatic Forceps lifted and secured the opened grippers together. A nerve hook teased the leaflets off clip arms. Inspection found no prolapse above the annular plane.An annuloplasty ring was implanted. A P2-P3 cleft was closed. Persistent medial commissural malcoaptation required two commissural advancement stitches. The valve tested well.
Cross-clamp was removed, right atrial Maze lesions created, and tricuspid annuloplasty implanted.
Sinus node dysfunction required BiV-ICD.
Six-month echocardiography showed mild MR, trace TR. EF 35%, EDD 4.7cm and LAdi 4.2cm. No AF per BiV-ICD. He is NYHA class II.