Paso a Paso

Técnica de implante de MitraClip

Dr. Fabián Julca

Hospital Clínico Universitario de Valladolid, España España , Valladolid

Dra. Ana Serrador

Hospital Clínico Universitario de Valladolid, España España , Valladolid

Dr. Ignacio J. Amat Santos

Hospital Clínico Universitario de Valladolid, España España , Valladolid

El procedimiento se puede dividir en cinco pasos:

  1. Punción transeptal e inserción del catéter guía dirigible.
  2. Cruce y dirección del clip.
  3. Alineamiento con la válvula mitral y línea comisural.
  4. Grasping o prehensión de los segmentos.
  5. Evaluación final y retirada del sistema.
 

1- Punción transeptal e inserción del catéter guía dirigible

Después de realizar la punción venosa femoral, idealmente derecha, y en ocasiones pre-cierre con sistema Proglide® (Abbott Vascular) se introduce la vaina de punción transeptal de 8 Fr a través de una guía de 0.032", y se realiza una punción transeptal utilizando una aguja de Brockenbrough bajo guía de ETE; la punción debe estar ubicada en la parte posterosuperior de la fosa ovalis obteniendo un suficiente espacio en la aurícula izquierda, brindando una orientación segura y un movimiento óptimo de la parte distal del sistema liberador de clip (SLC). En esta etapa, la altura de la punción transeptal del plano de la válvula es muy importante también, porque si la punción es demasiado baja, no hay suficiente espacio para moverse libremente dentro de la AI, y si es demasiado alto, no es posible al SLC alcanzar la zona de coaptación de los velos nativos. Una distancia óptima es de unos 35–45 mm desde el plano de la válvula en función del tipo de enfermedad (degenerativa vs. funcional)

La localización del chorro de insuficiencia mitral es importante, pues para alcanzar un chorro más medial la punción debe ser alta, y en el caso de un chorro lateral, la punción debe ser más baja.

 

Una vez que se introduce la vaina de punción transeptal a la AI se debe avanzar hacia la vena pulmonar izquierda para posicionar ahí una guía Amplatz Super Stiff™ de 260 cm (Boston Scientific) que dará un apoyo óptimo posteriormente.

 

Tras atravesar el septum interatrial se administran 100 UI/kg de HNF o alguna anticoagulación alternativa, de acuerdo con a la práctica clínica estándar, manteniendo un ACT de > 250 s en todo el procedimiento a partir de ese momento.

 

El catéter guía de 24 Fr se introduce luego dirigiéndolo hacia la vena pulmonar en la que hemos posicionado nuestra guía Super Stiff™, y el dilatador se retira con cuidado y lentamente para evitar la formación de burbujas de aire al vacío.

 

2- Cruce y dirección del clip

En la mayoría de los casos, este paso se puede llevar a cabo utilizando sólo la fluoroscopia. Si la aurícula es lo suficientemente grande, la maniobra más fácil y rápida es completar el cruce (deben alinearse los dos marcadores en el eje del SLC con el marcador en la punta de catéter guía dirigible (CGD)) apuntando con el clip a la vena pulmonar para que tener más espacio y movilidad, doblando poco a poco el sistema de liberación para orientar progresivamente el clip en dirección a la válvula mitral y yendo simultáneamente a posterior con el CGD y medial con la "rueda" medial/lateral (M/L). Debe evitarse el uso excesivo de la "rueda" M para crear menos tensión en el sistema.

 

3- Alineamiento con la válvula mitral y línea comisural

Una vez que manipulando el sistema de liberación hemos podido obtener una posición perpendicular y central con respecto a la línea de coaptación de las valvas mitrales, bajo ecocardiografía y guía fluoroscópica, el clip se dirige hasta que se alinea axialmente y se centra sobre el origen del chorro regurgitante. La trayectoria correcta del clip y la perpendicularidad de los dos brazos con respecto a la línea de coaptación de la valva mitral son comprobados utilizando vistas estándar ecocardiograma transesofágico; el 3D es particularmente útil para verificar la perpendicularidad de los brazos del clip respecto a la línea de coaptación. Una vez que el sistema ha sido alineado, el clip con los brazos abiertos se desplaza lentamente hacia el ventrículo izquierdo.

 

4- Grasping o prehensión de los segmentos

Este paso se realiza bajo la guía de ecocardiograma transesofágico (se aconseja el uso de X-plane). El clip con los brazos abiertos se retrae suavemente hacia la aurícula izquierda tratando de acomodar ambos velos; cuando están apoyados se bajan los grippers y se cierran los brazos del clip para realizar prehensión de los velos. La técnica de prehensión o grasping es diferente en función de la anchura del chorro de insuficiencia y de si se trata de una valvulopatía funcional o degenerativa, y todo ello condicionará el número de clips necesarios para un resultado óptimo.

 

5-Evaluación final y retirada del sistema

Cuando se ha liberado el clip se ha creado un doble orificio mitral. La ecocardiografía deberá confirmar la reducción de la regurgitación (el objetivo es que sea ligera, trivial o nula) y se debe verificar una prehensión óptima y estable de ambos velos.

 

A continuación, se confirmará que los brazos del clip están completamente cerrados y bloqueados y, tras esta verificación, se puede liberar.

 

Sin embargo, si la posición es considerada subóptima por la evaluación del ecocardiograma, el clip puede ser reabierto y reposicionado. Para ello, normalmente debe ser retirado a la aurícula izquierda, lo que requiere que los brazos sean invertidos en el ventrículo, proporcionando un perfil suave de retracción para evitar enredos con las cuerdas tendinosas. Una vez en posición adecuada y liberado del sistema, se podrá retirar el hijo de nitinol que se mantiene unido al clip hasta el último momento por si hubiese una suelta inapropiada del mismo. Finalmente, el sistema de liberación se endereza ligeramente y se retira, prestando atención para evitar dañar la pared auricular izquierda. Cuando sea necesario, por ejemplo, en el caso de valvulopatía degenerativa con ruptura de las cuerdas tendinosas y prolapso amplio, un segundo clip puede ser implantado, generalmente muy cerca del primer clip implantado. La necesidad de un segundo clip en otros escenarios debe ser evaluada, caso por caso. Seguidamente, se retira el catéter guía del septo y se debe verificar que no se hayan producido desgarros importantes del mismo.

 

Para finalizar, se retirará el catéter guía del paciente, previo ACT control, se iniciará la reversión de la heparina según el protocolo del hospital con sulfato de protamina, si se considera necesario, y el acceso femoral se cerrará con el sistema Proglide® empleado como pre-cierre, o bien con una sutura superficial en forma de ocho.

En esta edición

Caso Clinico

Implante de MitraClip en paciente con anuloplastia mitral fallida previa

Dr. Fabián Julca, Dra. Ana Serrador, Dr. Ignacio J. Amat Santos
Paso a Paso

Técnica de implante de MitraClip

Dr. Fabián Julca, Dra. Ana Serrador, Dr. Ignacio J. Amat Santos
Entrevista con los Expertos

Entrevista con el Dr. Maurizio Taramasso

Dr Adolfo Ferrero Guadagnoli
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