Interventions for valvular disease and heart failure

Cerebral embolisation during transcatheter edge-to-edge repair of the mitral valve with the MitraClip system: a prospective, observational study

EuroIntervention 2022;18:e160-e168. DOI: 10.4244/EIJ-D-21-00646

Tim Braemswig
Tim Bastian Braemswig1,2,3, MD; Madeleine M.D. Kusserow4,5, MD; Jochen Kruppa6, Dr. rer. hum. biol.; Markus Reinthaler7, MD; Hebun Erdur1,3, MD; Merve Fritsch1,8, MD; Jonathan Curio7, MD; Brunilda Alushi7,9,10,11, MD, PhD; Kersten Villringer3, MD; Ivana Galinovic3, MD; Christian Berger12, MD; David M. Leistner2,7,9, MD; Heinrich J. Audebert1,3, MD; Matthias Endres1,3,9,13,14, MD; Ulf Landmesser2,7,9, MD; Jochen B. Fiebach3, MD; Christian H. Nolte1,2,3,9,14, MD; Frederik Beckhoff7, MD; Alexander Lauten7,10, MD
1. Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany; 2. Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany; 3. Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; 4. Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; 5. Klinik für Innere Medizin, Bundeswehrkrankenhaus Berlin, Germany; 6. Institute of Medical Informatics, Charité – Universitätsmedizin Berlin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; 7. Department of Cardiology, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; 8. Department of Psychiatry, Campus Mitte, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; 9. German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany; 10. Department of General and Interventional Cardiology, Helios Klinikum Erfurt, Erfurt, Germany; 11. Department of Interventional Cardiology, Klinik Vincentinum Augsburg, Augsberg, Germany; 12. Department of Anesthesiology and Intensive Care Medicine, Campus Benjamin Franklin, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; 13. ExcellenceCluster NeuroCure, Berlin, Germany; 14. German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany

Background: New ischaemic brain lesions on magnetic resonance imaging (MRI) are reported in up to 86% of patients after transcatheter edge-to-edge repair of the mitral valve (TEER-MV). Knowledge of the exact procedural step(s) that carry the highest risk for cerebral embolisation may help to further improve the procedure.

Aims: The aim of this study was to identify the procedural step(s) that are associated with an increased risk of cerebral embolisation during TEER-MV with the MitraClip system. Furthermore, the risk of overt stroke and silent brain ischaemia after TEER-MV was assessed.

Methods: In this prospective, pre-specified observational study, all patients underwent continuous transcranial Doppler examination during TEER-MV to detect microembolic signals (MES). MES were assigned to specific procedural steps: (1) transseptal puncture and placement of the guide, (2) advancing and adjustment of the clip in the left atrium, (3) device interaction with the MV, and (4) removal of the clip delivery system and the guide. Neurological examination using the National Institutes of Health Stroke Scale (NIHSS) and cerebral MRI were performed before and after TEER-MV.

Results: Fifty-four patients were included. The number of MES differed significantly between the procedural steps with the highest numbers observed during device interaction with the MV. Mild neurological deterioration (NIHSS ≤3) occurred in 9/54 patients. New ischaemic lesions were detected in 21/24 patients who underwent MRI. Larger infarct volume was significantly associated with neurological deterioration.

Conclusions: Cerebral embolisation is immanent to TEER-MV and predominantly occurs during device interaction with the MV. Improvements to the procedure may focus on this procedural step.

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