To be honest, I never refer to height anymore from the mitral valve because I think it's not a great term. The bottom line is we're looking at the mitral valve annulus and we're looking at the fossa. And so if you think about it as distance rather than height, I think a lot of times people get a little tripped up in saying, I want to be at 4 centimeters and maybe you're still too anterior or whatever, but you're at 4 centimeters so you keep it, rather than if you actually come down a bit and the fossa is kind of an elliptical structure and you go more posterior, you might actually end up at 4.5 or 5 centimeters away. And I think understanding that relationship and thinking about it more as sort of distance rather than just height in the one view can help a lot with some of the huggers and things like that. I think that's a great point. And I'm going to talk about, I don't know how I keep getting the complications talk, but yet here I am. I'm going to talk about mitral valve complications, how to fix them, but the best thing to do is avoid them. And avoid them is by proper technique, being sure mitral valve is a very safe, very reproducible procedure. You can take a 93 year old, do a clip on them, send them home the next morning, 95% of the time. So you have time in the room. You have time to make decisions. You have time to take a clip on, you have time to take a clip off. So be methodical. So my Catholic school education is showing, but I want to talk about avoiding the occasions of sin. We talk about grasping issues and if you don't do it correctly, you'll get pinwheeling. Subvalvular-corter interaction, you'll get that if you're not set up properly, if you go too deep in the ventricle. Single leaflet detachment, we all worry about it. I'll talk about it a little bit. Air management, that's going to be one slide and again, that slide is your fault. And then we'll talk about worst case scenarios and catastrophes. So pinwheeling first is caused by non-perpendicular arm orientation. We just had two really good talks about how important it is to get a good grasp and I do prefer a simultaneous grasp. If not, you see the two panels on the top, that valve is torqued by the clip, all right, which causes inadequate MR reduction gradient and new, especially new eccentric jets. If you adjust the arm angle, that's better and I like in the short axis, transgastric imaging to be very helpful if you're not sure, okay? It's non-coaxial grasping. It's seen when the clip is not perpendicular to the commissural plane, it creates torsion on the valve. It manifests after clip release. So once you release the clip, you may be stuck with this. Common causes for it to line up properly, arm movement crossing the valve plane, excessive movement below the valve and the Tarzan maneuver. You're familiar with that. You grasp one, you pull over, you grasp the other and you let it go. If you're going to do that and sometimes you have to, you have to carefully assess whether or not you've got, you've maintained your perpendicularity. There are signals. Are the clip arms longer in the plane after crossing the valve? Do you see a new eccentric jet? And again, I like the transgastric view, it can be very helpful. If you see it, okay, firstly, careful alignment in 3D atrial view, close and cross, opens your clear leaflets, confirm and plane after crossing. I do try for simultaneous grasp whenever possible. I think it reduces the risk of this and I reserve independent grasping for leaflet optimization rather than initial grasp. Do not release the clip in the presence of a new eccentric jet, all right? You can think about it but don't do it because you'll have plenty of time to regret it if you do that. Okay, when in doubt, invert, come back to the atrium, set up, start over again, recross and then look at multiple views prior to release. Love valve or chordal entanglement, this is a problem with both platforms. A little bit more with G4 but you can also see it with Pascal. Chordal entanglement can result with excessive manipulation of the catheter below the annulus. It's more pronounced in the commissures and with calcified cords but can occur anywhere. And sometimes, if you're hopelessly stuck, you simply have to deploy it in the cords which does not help the MR and can complicate further attempts to clip, okay? So troubleshooting, again, we're going to try to avoid the occasions of sin. When you get to commissural anatomy or you know there's a lot of cords, maybe go with a smaller clip, okay? Avoid rotating arm angles of the ventricle at all if possible and certainly no more than 10 or 20 degrees. There are warning signs. If you start seeing your guide diving as you pull up to engage the leaflets, if you get an asymmetric grasp where you start to see a new eccentric jet, if you see any of these things you think got chordal involvement, invert, come back up and start over again. If it's having trouble inverting, you can cycle the grippers, you know, gentle posterior anterior torque will often free up and you want to torque away from the clot leaflet. However, avoid excessive attempts to free and there are worse things than having to deploy the cords. Here's a case that someone shared with me that they aggressively tried to get this clip up and when they took the clip back up, they found the cords were wrapped around the grippers in the up position and this patient had an untreatable flail and had to go to surgery. Air management, it's your fault. We all know that the valves aren't great but you got to just have meticulous cath lab technique, you got to flush it, aspirate, avoid pulling against the wall and you're dealing with big sheaths in the left atrium, you got to be meticulous about it, all right? SLDA, SLDA happens, okay? Single leaf detachment can occur and everybody who's done any number of mitral clips has seen it. The causes usually are insufficient tissue in one of the arms, excessive tension at the time of release, tissue quality and this can be acute or delayed. The best way to get around this is avoid it. Ensure leaflets in the gripper, open arms if you need to and inspect and make sure you're all the way in as Anita nicely showed how to do that. Measure length pre and post grip. Again, I like the transgastric short axis to see how much tissue you have and see your arm position and do not rely on the reduction of MR. Your delivery system is holding it tight. It may not be enough. It's important to see that but that is that you have an MR reduction doesn't mean you have a good grasp, okay? So what happens if you get an SLDA? The first thing you do and I think we talked about this a little bit already, assess the situation critically. Why do I have this and can I do better? If you're able to do better, if you have a strategy, treat with a repeat clip as close as possible to the first clip and then if needed another clip on the other side to bracket it. But be honest. If you can't do better, consider alternatives, surgical MVR, TMVR, medical therapy but don't just keep repeating the pattern, okay? Second time's a charm. You see on that last picture, we looked like we had an adequate landing zone and to the side and we went back. We put a clip on. We planned to put another one on the other side if necessary but this treated the problem and we're very happy with the result. And then lastly, catastrophes, all right? Weird things can happen and what I'd counsel you to do is, you know, you guys are all interventional cardiologists relying on your basic skills. Here's a case that I think you've seen this before, Anita. We had—we were aiming down to the valve, opening the clip and the clip just fell off the mandrel. Still had the lines on it. It's in the left atrium waving around. The rep says this never happens although Anita and I presented this case as a similar thing. We both had the same thing. So we relied on basic precepts. We didn't want to pull it. We wanted to get it out. We didn't want to pull it through the—and pull it off in the interatrial septum. So put a second wire across, balloon the septum, we're able to pull it down into the leg. You can see it in the picture on the far right there. We're holding it there. We've got another MitraClip system in the left side because we know we got to close that ASD we just made and once we do that, we're not clipping anything, right? So we went back with another system from the other side, performed a MitraClip, decent result, all right? We then sized the septum. You can see the clip there. You can see the balloon size of the septum. We took a pretty big balloon. It took a 15-millimeter balloon. These things are 20 millimeters in length and we pulled it back very carefully through the septum. We were able to close the ASD and then we went down to the leg with a vascular surgeon standing right next to me, scrubbed in, and a wire from a lower puncture so we had maintained access to the vein and we're able to simply with gentle traction take this out of the body, okay? And you can see the venogram there that we took at the end to make sure that we had an intact system and you can see what the clip looked like. And so basically, be prepared for almost anything. We had lots of time with this. We were phoning people all around the country, you know, take a minute. Don't rush into it. So in conclusion, avoid the occasions of sin. Do what everyone was saying up here how to do it. Do that. All right? Do as much in the atrium as possible. Minimize manipulation below the valve. Getting below the valve and trying to fix things is not a great strategy. Ensure adequate tissue insertion. If you SLDA, approach it systematically. Why did I get it? Can I do better? And how? And don't panic when catastrophe occurs. Troubleshoot. Use all your skills. And when needed, phone a friend. All right.

mitral valve complications

avoidance techniques

proper technique

methodical procedure

worst-case scenarios