and the SCAI Council for giving me the opportunity to talk about clip-steering alignment and trajectory and troubleshooting, and I'm actually an interventional structural cardiologist at Mount Sinai Heart. So the outline of the talk in the next eight, seven minutes is going to be just practical tips of how we do the steering, the lactatrium, and the common situations that we encounter, the troubleshootings, and the importance of trajectory and alignment. The most time you spend with the transeptal and with the maneuvering the lactatrium is actually going to result in optimizing the procedure results, and we all know that any residual MR of more than 1 plus or 2 plus is actually associated with bad outcomes. So talking about key principles for efficient tear, first of all, to anything, imaging is very important. Even if you're an implanter, you've got to really talk the language of echocardiogram and also utilize multimodality imaging. Like we saw beautiful images from the last presenter, how the 3-MPR was actually helpful in actually like grasping and optimizing the results, and also getting used to modified and off-axis views, and sometimes you don't get the same screening TE quality that you got before, like when the patient was actually not under complete anesthesia, then it also could be trivial changing the position of the patient by inflating a cup underneath the right shoulder or left shoulder so that you tilt the patient, and also working with the tidal volume and heart rate. So there are a lot of reports of actually rapid pacing the heart to decrease your coaptation gap and increasing the coaptation reserve, or even giving adenosine and causing a tension complete heart block to help you grasp, and those things are actually very helpful. And bottom line, you need to know the device and also know common things where you actually run into issues and how to troubleshoot, and we call this the knobology. You need to know like what are the knobs that's there and what do those knobs do, and those knobs may actually do something that's favorable for you at that moment, but could have actually done you something else, so you need to know how to actually correct for that. So the left atrial steering, when you look at the left atrial steering, so the things that you need to remember is to look at the morphology of the left atrium. All left atrium are the same. Some are taller, some are wider, some are stout, and patients with primary MR, you don't have a lot of left atrial space because they probably don't have that much remodeling compared to functional MR where there's a lot of remodeling of the left atrium. And we can emphasize more on the transeptal height, and then the clip trajectory. The trajectory of the clip has to be perpendicular to the annular plane and the grasping plane and the alignment of the clip, because if you have a clip that's rotated, that could actually result in increased shear stress pulling of the leaflets and leads to SLDA and whatnot. And also, you have to ask yourself, do you have any sufficient length in your clip delivery system? Meaning, like, is the clip delivery system long enough for you to go into the LV and actually long enough for you to actually pull up and grasp the leaflets? And the common situation that we encounter is the hyotohagur. So just going to quickly go through these. So you need at least 1 to 10 centimeter of the guide catheter in the left atrium. Less than 1 millimeter is not ideal. One centimeter is not ideal. In the same way, more than 2 centimeters is not ideal. The more you have, it's going to be hard for you to straddle. And then you've got to use both the TE and the fluoroscopy guidance, and then you advance the clip delivery systems. And you remove padelax on the clip, and you achieve straddle. So to start with, so right now, you're actually looking where you're going to advance your clip delivery system through the guide catheter. Before you come out, you just make sure that the arms are not superimposed. You actually, like, go back and forth on the clip delivery system to take the padelax off. So now that you know on the X-ray where you're looking at. And then when you actually straddle, this is what you're looking at. Like, the clip delivery system should be advanced completely in the left atrium safely without interacting with the lateral structures, and you need to have those two sleeve markers on either side of the tip of the guide catheter. And these are troubleshooting for straddle. So when you have a small left atria, what can you do? You can actually pull back the guide so that you actually have more space in the left atrium. Or you can even actually start doing early M before you straddle. So you don't have to wait until you straddle, but start using the M knob. And also, you can get more space. While you're doing all this stuff, you're going to interact either with the lateral structure or with the posterior structure. So you can go anterior posterior guide torque. And sometimes you have plus, which probably you had more when you actually have a Yodahugger, but not really here. And then there's the pre-M technique, which is actually you advance the clip delivery system and then M both simultaneously. But this is a very advanced maneuvering, and when you do that, you need to make sure that you're carefully looking at the echo and the fluoroscopy so that you're not actually causing any interactions with the structures in the lateral wall. So this is a typical view that you've got to tell your echocardiographer to show you where you actually see the tip of the clip, not the tip of the guide, and you make sure when you're actually doing this steering in the left atrium that you're actually not interacting anything with the lateral structures. And once you clear those structures, now you make sure that you clear the pulmonary vein and the left atrial appendage, and then you actually continue to M down with the posterior guide torque. And then as you do this, the two things that you need to make sure is to adjust the straddle. Why straddle is important? Because if only the straddle is there, the relationship between the guide and the clip delivery system is intact so that it can actually reproduce whatever the knobs are meant to be outside the body. If you don't actually have straddle, then you lose the relationship between that, and then you can't reproduce whatever the knobs are meant to be. And also, removing the slack on the DC handle will give you more workspace to work. Now moving on to the trajectory alignment, the first thing is you want to make sure that your alignment is good. So first you go in and make sure that you're like two centimeters above the valve now, and then you go back to your intercom visual view, explain LVLT view. You open your clip to 60 to 120. You identify the grippers, so you know you go down on the tactile, non-tactile, and the next thing is to check for the alignment. So this is the key thing. So you've got to make sure that the clip is actually right above or right at the place where you want to go, where the maximum PISA is, and make sure on the bicameral view you're actually perpendicular and you don't see any clip arms. So that tells you that you're actually at the right trajectory, and in LVLT view, you see the two clip arms that are actually equal on both sides, the anterior clip arm and the posterior clip arms. And you can see that the axis of the clip is actually perpendicular to the annular plane and the grasping plane. And then we check for the clip trajectory because there's a medial dive and there's a lateral dive. Since we actually did all those knobs, there's a tendency for the clips to actually dive one way or the other. So as you can see on the picture on the left, the clip is actually supposed to have a lateral dive as denoted by the red arrow mark, but then when you actually add more M to it, you actually go medial. But if you can do this, then your relationship between the guide catheter and the clip is actually not 90 degrees. So when you do more M, you make it 90. If they're already 90 degrees, you can do medial lateral by pushing and pulling in the whole system. As we know, pushing in the whole system goes lateral, and pulling the whole system goes medial. And also, you've got to test for your anterior and posterior trajectory, and that can be obtained by actually torquing the guide anterior and posterior. The next thing before you go into the LV is to actually look for the dive, medial and lateral dive. So once you're actually happy, then you actually go back and forth gently on your clip delivery system to see if there's a tendency for the guide or the clip delivery system to dive medial or laterally. And if you see that, then most of the times you're probably over M'd, so you let go of the M. But the thing that you need to make sure is the relationship between the guide catheter and the clip delivery system is 90 degrees, like how we see. And you also look for the anterior-posterior dive, which is actually completely under the guide. And we also started using the X-ray. So once you actually make sure that you actually have a good trajectory confirmed by TE, you go to a fluoroscopic view where there's no parallax on the clip, and then you CNA it so that you actually know whether, when you're going from LA to LV, if the valve actually – excuse me, the clip actually had a medial dive or a lateral dive. So we know on the X-ray when you go down, it's a medial dive, and on the X-ray going up, it's a lateral dive. Here's a classic example of where we actually had a – like, unfortunately, a huge medial dive. You can see here, like, it actually – the valve was – the clip was almost, like, commissural. So it tells you there was so much tension in the system, and probably there was over M'd, and that it was not actually taken care of. And the final result would be that, like, you have a lot of tension in the system. The last one is actually identifying some troubleshooting stuff. The most common stuff is the iota-hugger. And how do you find the iota-hugger? You can see that the shaft of the delivery system is actually parallel to the iota. And what happens when you go into the LV like that? The problem is you're not actually well-aligned to the leaflets, so you're actually going to get biased towards one leaflet, and then probably not able to grasp it all. This is commonly encountered when your transceptor is not pushier enough. This is actually the – how do you correct for it? This is an in vitro, like, pictorial from Paltoraja, so you actually had plus to it. When you had plus, you can see on the top, second picture D, that the clip stands up and go posterior. And how do you account for that is actually you do anterior A-knob, and that takes you lateral and then finally you M. So bottom line, when you have iota-hugger, look at hat plus and see how medial you go, and then you contract for that. See how lateral you go and you contract for that by doing either M-knob or by actually pulling the system back. So this is an example of how we did – like, how the iota-hugger was taken care of. And this is 3DT, this is without MPR, where you're actually looking at – before you enter the LV, this is the last step that you need to do. All you're looking at is the surgeon's view, where the commissure is at 10 and 2, could have slightly counter-clocked, but you want to make sure that the clip arm, which is the red line, is actually perpendicular to the white mitral leaflet plane. The reason why this is important, again, is actually you get a good grasping and better outcomes here. And then how do you do it? People actually open the clip up to 120. Some people open the clip up to 60. But if you open the clip only to 60, then your counter-clockwise – because your trajectory is not good on a 3D, it's known that, like, when it's 60 degrees, the radius of deviation is very less, meaning that, like, it's not going to go overcorrected. So if you counter-clock, it might counter-clock more when it's actually wide open or 120 degree open. So this is something to keep in mind. Finally, is entering into the LV. Like I said, we actually – after making sure on 2D, bicarbonate LVOT, 3D, and 3D NPR, you actually take your X-ray to a view where you take complete parallax off, and you CMA that. So, for example, like, it's usually an R-A view, R-A or Cranie view. And then you actually make sure that's your baseline before you go in. And then when you actually go in, we actually – in Montana, we go in for all the cases with the clip arms closed, but also – but the IFU says that you have to go in with the clip arms a little open so that you don't get engaged in cords or other secondary structures. And use all the modalities to your advantage. Use fluoroscopy, TE, to see if there's actually a rotation of the clip or medial-lateral dive. So this is actually some examples of how the clip can rotate. So there's actually just not the medial dive and lateral dive. There's not just the anterior and the posterior dive, but also the internal clip rotation that you need to account for by actually counter-clocking gently on the clip delivery system. And how do you know you're rotated? Because you lose parallax on the X-ray, and then your echocardiographer is saying that they can't see the clip arms very well, that they saw just value in the LA. So this is – and then once in the LV, you ought to keep maintaining the same alignment that you have, that you started with, that you ought to be at 90 degrees, and your arms are not seen on the bicameral view, and they're equal on the LVOT view. And during while you're grasping, you also want to make sure that there's no parallax in the clip. If there's a parallax in the clip on X-ray, and then your echocardiographer is not able to view the arms properly, that means that the clip has actually spun or rotated. You counteract it by doing a counter-clock or clock gentle action. So finally, procedural purge. Do all the maneuverings that you want in the left atrium, and try not to do anything in the left ventricle. It doesn't matter if the left ventricle is dilated or not. And you actually watch for all the dives before you enter the left ventricle, and use fluoroscopy as well. And then the most important thing is obtain ideal transceptal height. Thank you very much.

clip steering alignment

trajectory

transcatheter mitral valve repair

multimodality imaging

complications