Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 23-24
Adaptive responsiveness of anesthesiologists to the rapidly expanding hybrid cardiovascular procedures: MitraClip, the percutaneous Alfieri

1 Associate Professor of Anesthesiology, Harvard Medical School, Director of Cardiovascular Anesthesia Research, Director of Residency Research, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
2 Visiting Associate Professor of Anesthesiology, Director of Intraoperative Echocardiography Education, University of Pittsburgh Medical School- Presbyterian Hospital, Pittsburgh, PA, USA

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Date of Web Publication2-Jan-2014

How to cite this article:
Subramaniam B, Subramaniam K. Adaptive responsiveness of anesthesiologists to the rapidly expanding hybrid cardiovascular procedures: MitraClip, the percutaneous Alfieri. Ann Card Anaesth 2014;17:23-4

How to cite this URL:
Subramaniam B, Subramaniam K. Adaptive responsiveness of anesthesiologists to the rapidly expanding hybrid cardiovascular procedures: MitraClip, the percutaneous Alfieri. Ann Card Anaesth [serial online] 2014 [cited 2022 Jan 26];17:23-4. Available from:

The innate desire to expand oneself is the major driving force behind human growth and evolution. Cardiovascular medicine is a classic example of such growth. Constant desire to improve a patient's outcome has brought together the skills of interventional cardiologist, cardiovascular surgeon, anesthesiologists, and radiologists to invent several new approaches to cardiovascular diseases. [1],[2] Endovascular and hybrid aortic aneurysm repair, transcatheter aortic valve implantation, transcatheter atrial septal defect closure, and catheter-based left atrial appendage closure are few well-established recent advances in hybrid cardiovascular medicine. These "minimally invasive" interventional and hybrid approaches reduce surgical trauma and improve perioperative morbidity and mortality.

Currently, interventional and hybrid procedures are viewed as an attractive alternative for standard open surgical procedures, especially in high-risk patients. As the device technology is evolving rapidly to better designs to meet patients' needs and the experience of the cardiovascular teams is improving, several such procedures have the potential to become the standard of care, as the open surgical approach to complex diseases is associated with extensive peri-procedure morbidity and mortality.

Alfieri stitch, a suture that brings together the A2 and P2 scallops of mitral valve, was originally done to treat systolic anterior motion of mitral leaflets. This decreased the residual mitral regurgitation (MR), but did not entirely cure it. This simple procedure was the inspiration behind the percutaneous MitraClip placement. MitraClip alleviates symptoms in patients with severe MR who were deemed high surgical risk. Follow-up outcome studies with improved operator and team skills in managing these high-risk patients have led to expansion of the indications for MitraClip.

At this point of time, institutional experience dictates clinical practice that includes patient selection. The complex design of hybrid cardiovascular suites to enable use of interventional techniques [3] combined with advanced imaging modality carry a significant price tag. In this era of cost containment, significant outcome benefits should be proven to advance the practice of any new technology. Perioperative major adverse cardiac events are decreased in patients receiving MitraClip compared with open surgery patients. [4] However, the open surgical procedure for MR retains its advantage over percutaneous repair at 1 and 4 years while comparing the need for reoperations. When evaluated in patients with functional MR subgroup, the efficacy of both approaches was comparable. As we move along the learning curve, we will identify clear indications for these procedures. These growing pains are mitigated by the significant potential they carry to advance the hybrid technology and thereby realize the full potential in minimizing patient morbidity.

In this issue of Annals of Cardiac Anaesthesia, [5] Kothandan et al., have described the anesthetic challenges that come with the MitraClip procedure. The initial introduction of this procedure in their institute warranted maximum protection of the patient, as reflected by their invasive lines. As their team went through the learning curve, invasive lines were not placed in their later cases. The relative ease with which the later procedures have been done is encouraging and this can only lead to expansion of these procedures in operating rooms across the world. The authors describe the valuable lessons learnt during the peri-procedure management. The significant issues to remember in this hybrid procedure, to highlight a few, are: (a) ability to manage hemodynamic disturbances associated with the procedural manipulations in high-risk surgical patients; (b) ability to handle any kind of life-threatening procedural complication such as device migration or rupture of major cardiovascular structures; (c) perform the dual role of anesthesiologist and echo-cardiologist; (d) ability to perform efficiently in the challenging environment of hybrid operating rooms or catheterization laboratories where the procedure is performed; (e) evaluate the neurological well-being of the patient during intravascular and cardiac manipulations by neuro-monitoring; and (f) administer light anesthetic to facilitate wake up of the patients at the end.

Evaluation of the result of the MitraClip procedure is done by a team approach involving interventional cardiologist, cardiothoracic surgeon, and cardiovascular anesthesiologist. A reduction in the severity of MR without any significant mitral stenosis is considered as a satisfactory result. Repeated attempts with longer procedure duration may be needed in some patients to achieve a satisfactory result. As MitraClip reduces the MR severity but not completely take it away, the left ventricle could potentially handle this immediate challenge better, compared to the open surgical approach where there is complete correction of MR.

As the hybrid procedures become increasingly used for managing various pathologies, it will be a challenge for the anesthesiologists to (a) learn new procedures, (b) take their patients through the procedure without a major event, (c) be prepared for those procedures that might fail, and (d) maintain their importance and relevance as perioperative physicians. With the advanced 3-dimensional echocardiographic skills, anesthesiologists are placed in a unique position to not only care for these very sick patients but also guide the proceduralist in accomplishing hybrid procedures. Furthermore, it is easy to imagine that in future, there will be a physician termed the all-star cardiovascular proceduralist who will have combined skills of a cardiologist, cardiovascular surgery, and radiology. We, as anesthesiologists, can rise to this challenge when we (a) become a complete perioperative physician (true patient advocate) and (b) improve our imaging skills in advanced ultrasonography [3-D, intracardiac echocardiography (ICE), transthoracic echocardiography (TTE)] to help guide the cardiovascular proceduralist. We would go farther and propose that anesthesiologists should potentially learn other point-of-care imaging techniques such as cardiac magnetic resonance, computerized tomographic scans, etc., to help guide hybrid treatment procedures. These additional skills, apart from the role of perioperative physician, help us adapt to the ever-changing landscape of cardiovascular procedures.

   References Top

1.Leacche M, Umakanthan R, Zhao DX, Byrne JG. Surgical update: Hybrid procedures, do they have a role? Cir Cardiovasc Interv 2010;3:511-8.  Back to cited text no. 1
2.Ringewald JM, Stapleton G, Suh EJ. The hybrid approach--current knowns and unknowns: The perspective of cardiology. Cardiol Young 2011;21 Suppl 2:47-52.  Back to cited text no. 2
3.Kpodonu J. Hybrid cardiovascular suite: The operating room of the future. J Card Surg 2010;25:704-9.  Back to cited text no. 3
4.Mauri L, Foster E, Glower DD, Apruzzese P, Massaro JM, Herrmann HC, et al. 4-year results of a randomized controlled trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol 2013;62:317-28.  Back to cited text no. 4
5.Kothandan H, Ho VK, Keong YK, Chih HN. Anesthesia management for MitraClip device implantation. Ann Card Anaesth 2014;17:17-22.  Back to cited text no. 5
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Correspondence Address:
Balachundhar Subramaniam
Associate Professor of Anesthesiology, Harvard Medical School, Director of Cardiovascular Anesthesia Research, Director of Residency Research, Beth Israel Deaconess Medical Center, Boston, MA 02215
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Source of Support: None, Conflict of Interest: None

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