ABC | Volume 114, Nº1, January 2019

Statement Position Statement of the Brazilian Cardiology Society and the Brazilian Society of Hemodynamics and Interventional Cardiology on Training Centers and Professional Certification in Hemodynamics and Interventional Cardiology – 2020 Arq Bras Cardiol. 2020; 114(1):137-193 6.2.2.13. Transcatheter Mitral Valve Repair Mitral valve insufficiency, one of the most common acquired valve diseases, frequently affects elderly patients, who present many comorbidities and, at times, are not able to be treated conventionally by mitral valve surgery due to the high operative risk of death and complications. 42,43 TMVR is a viable option for treating moderate or severe mitral insufficiency, in symptomatic patients, patients with high surgical risks, or inoperable patients, with degenerative or functional etiology, as an alternative to conventional surgical treatment or isolated clinical treatment. 53-59 Interventional cardiologists who perform this procedure must have specific training in cardiovascular catheterization, required during professional qualification, as well as experience in diagnostic procedures for valve diseases, which are essential to their safety and success. 53-59 Mastery of the transseptal puncture technique is also necessary, as is knowledge of its anatomical relation with the pulmonary artery, the coronary sinus, the aorta, and other cardiac structures, because, in some cases, accidents may occur during puncture of the interatrial septum. Specific knowledge is also necessary regarding the general characteristics of implantable medical devices utilized by this technique and their appropriate indications, as well as understanding of anticoagulation control and appropriate management of possible complications, such as cardiac tamponade, cardiac or vascular perforation, clip embolization, thrombus formation, infectious endocarditis, cardiac arrhythmias, and other complications. It is recommended that TMVR involve a multidisciplinary program that includes the contributions of a clinical cardiologist, an echocardiographist, a radiologist, and a cardiac surgeon. Qualification of physicians for mitral clip therapy requires thorough knowledge of normal cardiac anatomy, anatomy of right and left chambers, and, above all, an understanding of anatomical anomalies, their functional repercussions, and the corresponding relative values of therapeutic options. The duration of the learning curve varies significantly in accordance with the operator’s degree of familiarity with procedures for congenital and/or structural heart diseases, as well as the frequency with which the procedure is performed. Although there is no consensus in the literature with respect to the minimum number of cases required in order to complete this learning curve, within the Brazilian context, considering the complexity of the intervention, it is possible to estimate that a beginner operator will reach the level of proficiency and safety necessary for TMVR once he or she has performed approximately ten cases. 6.2.2.13.1. Basic Knowledge • Natural history and etiology of mitral valve insufficiency. • Hemodynamics of mitral insufficiency. • Interpretation and familiarity with different imaging exams: TTE, TEE, CT, MR, and angiography. • Knowledge of current Brazilian guidelines for treating mitral valve insufficiency. • Therapeutic options. • Indications for intervention. 6.2.2.13.2 Interventional Cardiologists’ Abilities • Hemodynamic interpretation of pressure curves. • Access management. • Ability with the introducers, wires, and catheters utilized. • Angiographic projections for performing the procedure. • Pre-procedure assessment of TEE for patient selection. • Recognition and rapid management of complications (vascular complications, stroke, cardiac tamponade, hemodynamic collapse, cardiac perforations, arrhythmias/ atrioventricular blocks, etc.). • Immediate and long-term post-procedural care. 6.2.2.14 Transcatheter Pulmonary Valve Bioprosthesis Implantation Right ventricular outflow tract dysfunctions are frequently involved in the late postoperative period of right ventricle to pulmonary artery (RV-PA) connection surgeries in patients with tetralogy of Fallot, pulmonary atresia, truncus arteriosus, or any other congenital heart disease in which pulmonary flow must be anatomically restored. In this context, pulmonary insufficiency and, mainly, its association with pulmonary stenosis (double pulmonary valve lesion) may result in dilatation and progressive right ventricular dysfunction, exercise intolerance, potentially severe arrhythmias, and sudden death. Reestablishing pulmonary valve function at an appropriate moment may reverse this process, thus restoring ventricular function and improving symptoms. 60,61 Surgical replacement of the pulmonary valve requires extracorporeal circulation, which may further aggravate right ventricular function, when it is already compromised. 61 There are several options and surgical techniques for treating pulmonary insufficiency, including the use of cadaver homografts, valved synthetic conduits, bovine jugular vein grafts, or a bioprosthetic valve implanted directly in the right ventricular outflow tract. With the passing of time, however, all of these conduits or surgically implanted valves present varying degrees of dysfunction characterized by stenosis, accompanied or unaccompanied by insufficiency. It is estimated that after four to five years, 25% of patients who have undergone a homograft implantation will require some type of intervention to increase the longevity of these conduits. 62 The probability of not needing a conduit replacement is approximately 50% over ten years, with even less favorable figures in small children. 62 In 2011, the American Heart Association (AHA) published a scientific statement on interventions in congenital heart diseases, in which the recommendation for TPVI was classified as IIa (level of evidence B), stating that, “It is reasonable to consider percutaneous pulmonary valve replacement in a patient with an RV-to-pulmonary artery conduit with associated moderate to severe pulmonary regurgitation or stenosis provided the patient meets inclusion/exclusion criteria for the available valve.” 63 The TPVI procedure should be performed in a conventional catheterization laboratory or in a hybrid operating room, and the institution should have a group of professionals qualified to treat congenital and structural heart diseases (heart team), made up of a clinical cardiologist, a cardiologist with a 154