MItraClip Vs Pascal

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Curious if any of the structural guys here are switching to Pascal.
Pascal seems to be slightly more echogenic and crossing the septum seems more forgiving if you can't get 4.5 cm height for whatever reason. The ace variant seems to be a nice size, while the 10 seems to be quite large with resulting higher gradients (this is anecdotal based on 2 cases). I like how the Pascal edge to edge tends to not be as rigid as the MitraClip while maintaining a good tissue bridge.
We are exploring Pascal because we have found a few cases where the clip loosened up over time. Might just be a few outliers, but curious if anyone else is adopting Pascal over MitraClip or if there are specific situations you would choose one over the other.
 
We've got two groups doing clips. One uses primarily MitraClip, the other Pascal. So it's hard for a true comparison since the operators are also different. But I do feel as though the Pascal device gives a little more control of where to grasp the leaflets. And I like the grasping arms a little better. Definitely easier to confirm contact with grasping arms, which is super relevant once you're doing >1 clip.
 
thinkorswim said:
Our cardiologists switched to Pascal. They seem to like it since it's less traumatic on the leaflets and the delivery system is more elegant.

I still think the procedure is dumb and hate them both equally.
Click to expand...
I find reduction of severe MR with coanda and reversal of flow in the pulmonary veins to trace MR and normalization of PVF highly satisfying in a patient who is not a candidate for surgical MVR. I also find the imaging very interesting compared to an AVR or CABG. The interaction btw/ cards/ct surg and ct anesthesia is highly interactive.

Right now MC/abbot have most of the market share, but seems like that may be changing. Edwards seems to be making some progress with Pascal. I believe SLDA is lower with Pascal. Abbot does offer more device options (xt, xtw, nt, ntw).

Will be interesting to see what happens over the next few years.
 
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Pascal seems better since it allows to grab each leaflet sequentially, instead of simultaneously like the MitraClip.

Those “loosened” clips most likely never grabbed the leaflet properly.
 
urge said:
Pascal seems better since it allows to grab each leaflet sequentially, instead of simultaneously like the MitraClip.

Those “loosened” clips most likely never grabbed the leaflet properly.
Click to expand...
Our clips I've seen them close the gripper arms separately im fairly sure. In fact I think they always close them separately

Never done or even heard of a Pascal until now.
I find the whole procedure tedious and dont reallu like it but we've definitely had some great successes with it... we even offer a sort of emergency clip procedure for ischemic pap rupture and the like. N=3 survived to discharge.

They really need to figure out the next generation solution. Edge to edge repair i hope isn't the best perc option for tri/mitral.
 
Our implanters seem to prefer mitraclip I think because of the size options which is important when you are doing multiple clips or have variable pathology. I felt like imaging for both were pretty similar.

Triclips have essentially disappeared and instead we are doing 2-3 EVOQUEs a day for TR. I actually find the imaging for EVOQUEs easier than triclips.

Seems like we’ll have to wait for legit data to come out to point us in the right direction for the patient.
 
Radar26 said:
Our implanters seem to prefer mitraclip I think because of the size options which is important when you are doing multiple clips or have variable pathology. I felt like imaging for both were pretty similar.

Triclips have essentially disappeared and instead we are doing 2-3 EVOQUEs a day for TR. I actually find the imaging for EVOQUEs easier than triclips.

Seems like we’ll have to wait for legit data to come out to point us in the right direction for the patient.
Click to expand...
2-3 per day? Good lord. All non-surgical? Or data supports equal outcomes?
 
Radar26 said:
Our implanters seem to prefer mitraclip I think because of the size options which is important when you are doing multiple clips or have variable pathology. I felt like imaging for both were pretty similar.

Triclips have essentially disappeared and instead we are doing 2-3 EVOQUEs a day for TR. I actually find the imaging for EVOQUEs easier than triclips.

Seems like we’ll have to wait for legit data to come out to point us in the right direction for the patient.
Click to expand...
Never even heard of EVOQUE before this moment. Looks awesome!
 
sevoflurane said:
I find reduction of severe MR with coanda and reversal of flow in the pulmonary veins to trace MR and normalization of PVF highly satisfying in a patient who is not a candidate for surgical MVR. I also find the imaging very interesting compared to an AVR or CABG. The interaction btw/ cards/ct surg and ct anesthesia is highly interactive.
Click to expand...

My comment was tongue in cheek. They are definitely the most technically challenging procedures we do.

But I would much rather do a pump case than care for a decompensated heart failure patient while doing TEE at the same time. Not to mention the high radiation exposure and the Toradol shot I need at the end from the physical toll it takes on my body.
 
thinkorswim said:
Our cardiologists switched to Pascal. They seem to like it since it's less traumatic on the leaflets and the delivery system is more elegant.

I still think the procedure is dumb and hate them both equally.
Click to expand...

thinkorswim said:
My comment was tongue in cheek. They are definitely the most technically challenging procedures we do.

But I would much rather do a pump case than care for a decompensated heart failure patient while doing TEE at the same time. Not to mention the high radiation exposure and the Toradol shot I need at the end from the physical toll it takes on my body.
Click to expand...

Never done or seen a Pascal.

Only thing I dislike about Mitraclips is that they (for some reason) bring another cardiologist in to do the TEE.

It makes the case easier for me, but I'd prefer to do the TEE myself, as I do for LAA closures and the odd TAVR that gets general and every other non-Mitraclip TEE-getting procedure we do. We have an excellent cardiology dept and they're usually pretty good at getting the images, but often I find myself thinking I could do better.

And it gets crowded in my space with an echo tech, device rep, and cardiologist all clustered around.
 
sevoflurane said:
Curious if any of the structural guys here are switching to Pascal.
Pascal seems to be slightly more echogenic and crossing the septum seems more forgiving if you can't get 4.5 cm height for whatever reason. The ace variant seems to be a nice size, while the 10 seems to be quite large with resulting higher gradients (this is anecdotal based on 2 cases). I like how the Pascal edge to edge tends to not be as rigid as the MitraClip while maintaining a good tissue bridge.
We are exploring Pascal because we have found a few cases where the clip loosened up over time. Might just be a few outliers, but curious if anyone else is adopting Pascal over MitraClip or if there are specific situations you would choose one over the other.
Click to expand...

You have a say in what devices the surgeons/proceduralists use as a cardiac anesthesiologist? If so, seems like the exception rather than the rule.
 
pgg said:
Only thing I dislike about Mitraclips is that they (for some reason) bring another cardiologist in to do the TEE.
Click to expand...

We do imaging for most but one of the cardiology groups at my shop brings in their own cardiologist for imaging. It’s a money loser for them, but they do it because they feel it’s best for the patient. I can’t say that I disagree… these patients are quite sick. It’s not about my ego, it’s about patient safety.


SRYSPAC said:
You have a say in what devices the surgeons/proceduralists use as a cardiac anesthesiologist? If so, seems like the exception rather than the rule.
Click to expand...

Seriously… I’m just glad to be invited for a round of golf with the surgeons and the rep every now and then.
 
Who cares. These procedures are mostly govt payers and pay us nothing, You all need to realize you’re just the cardiac surgeons nurse as that’s how they see you. Cheaper than a cardiologist. That’s it, facility gets paid $50,000 a procedure and the facility pays all of these cardiologists over 7 figures. they’ll replace you with a cheaper option eventually if they can. But if they can’t I would implore you to use your leverage and make them pay you seven figures. Don’t be a nurse
 
thinkorswim said:
My comment was tongue in cheek. They are definitely the most technically challenging procedures we do.

But I would much rather do a pump case than care for a decompensated heart failure patient while doing TEE at the same time. Not to mention the high radiation exposure and the Toradol shot I need at the end from the physical toll it takes on my body.
Click to expand...
Agree completely 👍🏼.

Technical and specific TEE skills that require confident answers, radiation exposure as well as sick patients indeed make the day a little more busy.

I wouldn’t want to do structural heart every day as much as I enjoy it. To me a 3-4 hour MVR can be a chill morning with equally satisfying echo pathology.
 
SRYSPAC said:
You have a say in what devices the surgeons/proceduralists use as a cardiac anesthesiologist? If so, seems like the exception rather than the rule.
Click to expand...
We have an exceptionally tight structural team made up of great people that respect each other’s opinion. Zero toxicity.
 
pgg said:
Never done or seen a Pascal.

Only thing I dislike about Mitraclips is that they (for some reason) bring another cardiologist in to do the TEE.

It makes the case easier for me, but I'd prefer to do the TEE myself, as I do for LAA closures and the odd TAVR that gets general and every other non-Mitraclip TEE-getting procedure we do. We have an excellent cardiology dept and they're usually pretty good at getting the images, but often I find myself thinking I could do better.

And it gets crowded in my space with an echo tech, device rep, and cardiologist all clustered around.
Click to expand...

I totally get this. Our cards have other things to do and there is already a structural cardiologist there as well as a rep to lend a hand. Probably better for everyone if CT anes covers it. 🤷🏼‍♂️
 
pgg said:
Never done or seen a Pascal.

Only thing I dislike about Mitraclips is that they (for some reason) bring another cardiologist in to do the TEE.

It makes the case easier for me, but I'd prefer to do the TEE myself, as I do for LAA closures and the odd TAVR that gets general and every other non-Mitraclip TEE-getting procedure we do. We have an excellent cardiology dept and they're usually pretty good at getting the images, but often I find myself thinking I could do better.

And it gets crowded in my space with an echo tech, device rep, and cardiologist all clustered around.
Click to expand...

Isn’t this due to CMS billing requirements that prohibit anesthesiologists from billing structural TEE and anesthesia at the same time? It has been a barrier at my practice (MD only).

Cardiology, sonographer, and rep will be involved in all Watchman’s and clips.
 
thinkorswim said:
My comment was tongue in cheek. They are definitely the most technically challenging procedures we do.

But I would much rather do a pump case than care for a decompensated heart failure patient while doing TEE at the same time. Not to mention the high radiation exposure and the Toradol shot I need at the end from the physical toll it takes on my body.
Click to expand...
My understanding is you are not allowed to do the TEE and the anesthesia together for those cases. Requires two people. For billing purposes.
 
Remxed said:
Isn’t this due to CMS billing requirements that prohibit anesthesiologists from billing structural TEE and anesthesia at the same time? It has been a barrier at my practice (MD only).

Cardiology, sonographer, and rep will be involved in all Watchman’s and clips.
Click to expand...
Could be -

We don't bill for anything any more. The hospital does it (poorly, I hear) and we're paid $X for Y lines every day, no matter the cases (or lack thereof) or insurance (or lack thereof).

We have a sonography tech and a rep present for Watchmans and TAVRs, but we do the imaging for those. I don't know if or why Mitraclips are different from a billing perspective.
 
93355 can’t be billed by the same provider also billing any anesthesia CPT codes in any location concurrently. Imager must not be providing any other services concurrently in other words.

This is obviously intended to reflect the intensity of the burden on the imager compared to other cases requiring TEE. I actually put a stop to our department being asked to provide both the anesthesia and the TEE and butted heads with cardiology over it.
 
T-burglar said:
93355 can’t be billed by the same provider also billing any anesthesia CPT codes in any location concurrently. Imager must not be providing any other services concurrently in other words.

This is obviously intended to reflect the intensity of the burden on the imager compared to other cases requiring TEE. I actually put a stop to our department being asked to provide both the anesthesia and the TEE and butted heads with cardiology over it.
Click to expand...


That's inclusive of any structural imaging? Last I looked into this, and I went up the ranks of my friends in SCA, this was limited to mitral clips only. It's been a couple years.

I'd love to read background into this, if you have a source or a link.

I'm also intrigued to see how they would determine concurrency. The echo guidance portion of these procedures is almost never the entire duration. There is no start or end time to my TEE note, just a time stamp of when it is entered.
 
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Nobody really wants the interventional echocardiography service to be on their departments’ balance sheet.

It reimburses garbage so it ‘wastes’ a cardiologists’ day. Same for a CT anesthesiologist and their home department.

If your anesthesiologists agree to do both the anesthesia and the imaging for intense procedures like mitral or tricuspid interventions then the 93355 code can be written off as the cost of doing business but it’s kind of bull**** to ask an anesthesiologist to do both as the NCCI edits reflect that the imaging is a significant undertaking by itself .

Maybe in the future mitral and tricuspid interventions will be like TAVRs or LAAOs and quick in and out procedures but they aren’t right now in many cases .

If you read the ASE pubs you can find a lot of discussion about how interventional echo is severely undervalued .
 
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Seems like the 93355 reimbursement is bundled into the overall reimbursements for these procedures. That explains the lucrative money in LAAOs. Time to start clawing that money back from my cardiologist friends.

Honestly, I'm not too worried about collecting on the 93355. Can't be much, I'll just continue to image while I staff another room. I'm employed, not my business.
 
Pascal >>> MitraClip.

The ability to evert device allows you to sneak into tight spaces, allows easier treatment of commissural pathology and lets the operator free the device when stuck on the subvalvular apparatus.

Also, the P10 has the wider central spacer which is really useful in functional MR when leaflets are restricted and annulus dilated - allows an adequate grasp without pulling as much leaflet tissue.
 
T-burglar said:
Nobody really wants the interventional echocardiography service to be on their departments’ balance sheet.

It reimburses garbage so it ‘wastes’ a cardiologists’ day. Same for a CT anesthesiologist and their home department.

If your anesthesiologists agree to do both the anesthesia and the imaging for intense procedures like mitral or tricuspid interventions then the 93355 code can be written off as the cost of doing business but it’s kind of bull**** to ask an anesthesiologist to do both as the NCCI edits reflect that the imaging is a significant undertaking by itself .

Maybe in the future mitral and tricuspid interventions will be like TAVRs or LAAOs and quick in and out procedures but they aren’t right now in many cases .

If you read the ASE pubs you can find a lot of discussion about how interventional echo is severely undervalued .
Click to expand...

I like the structural room because it uses and expands my TEE skills. And I agree that doing both should be viewed as 1.5 FTE. The hospital needs to realize we’re keeping their cardiologist in clinic pumping out consults while also keeping the implanters happy and the cases moving along. Politics do creep in. People trying to explain why they send cardiologists to an imaging super fellowship.

As a side our echo department loves when we do the imaging for structural because we don’t typically ask for a sonographer tech which frees them up to staff other areas. Lots of people saving/earning money. You’re welcome.

Now- when a CV service line starts to pay you 1k-2k stipend (on top of what you bill) to do the imagining for a room you’re stuck in anyway I worry less and less about my ability to collect to the max on the cpt code for structural TEE. I don’t disagree that the billing limitation is there. Gotta leverage around it is my perspective.
 
Our structural guy wants the same person doing all of his TEEs for these. Since I'm not going to be at his scheduling beck and call, I'm perfectly happy with him using a cardiologist.

Since I can't echo for it, I've pawned the anesthesia off on my non-cardiac colleagues. The cases are boring AF, and the anesthesia is easy, if I'm not doing the echo. I still participate on the random occasions when my number matches the line in our randomized assignment pool.
 
Radar26 said:
I like the structural room because it uses and expands my TEE skills. And I agree that doing both should be viewed as 1.5 FTE. The hospital needs to realize we’re keeping their cardiologist in clinic pumping out consults while also keeping the implanters happy and the cases moving along. Politics do creep in. People trying to explain why they send cardiologists to an imaging super fellowship.

As a side our echo department loves when we do the imaging for structural because we don’t typically ask for a sonographer tech which frees them up to staff other areas. Lots of people saving/earning money. You’re welcome.

Now- when a CV service line starts to pay you 1k-2k stipend (on top of what you bill) to do the imagining for a room you’re stuck in anyway I worry less and less about my ability to collect to the max on the cpt code for structural TEE. I don’t disagree that the billing limitation is there. Gotta leverage around it is my perspective.
Click to expand...
Are you being paid an extra stipend to do the imaging?

Is that coming from the hospital or your group?
 
Interesting to hear that a lot of the imaging is done by cardiology. That seems like a waste to me. They can read echos in the reading room or do procedures that pay in orders of magnitude higher for their time rather than being the imager for the room. If our schedule allows it we occasionally have a second ct anesthesiologist in the room doing anesthesia and a ct anesthesiologist doing the imaging. I sincerely believe that CT anesthesia is the perfect physician to guide imaging in the structural heart rooms. It's busy, and I wouldn't want to do it everyday... but it also can be super satisfying (to me at least).
 
dutchmaster504 said:
Pascal >>> MitraClip.

The ability to evert device allows you to sneak into tight spaces, allows easier treatment of commissural pathology and lets the operator free the device when stuck on the subvalvular apparatus.

Also, the P10 has the wider central spacer which is really useful in functional MR when leaflets are restricted and annulus dilated - allows an adequate grasp without pulling as much leaflet tissue.
Click to expand...
We trialed a p10 on a jet originating near the lateral commissure. Gradients went from 2mmHG to 8+mmHg. Valve area was not unusually small either. Had to bail on the p10.
 
Radar26 said:
I like the structural room because it uses and expands my TEE skills. And I agree that doing both should be viewed as 1.5 FTE. The hospital needs to realize we’re keeping their cardiologist in clinic pumping out consults while also keeping the implanters happy and the cases moving along. Politics do creep in. People trying to explain why they send cardiologists to an imaging super fellowship.

As a side our echo department loves when we do the imaging for structural because we don’t typically ask for a sonographer tech which frees them up to staff other areas. Lots of people saving/earning money. You’re welcome.

Now- when a CV service line starts to pay you 1k-2k stipend (on top of what you bill) to do the imagining for a room you’re stuck in anyway I worry less and less about my ability to collect to the max on the cpt code for structural TEE. I don’t disagree that the billing limitation is there. Gotta leverage around it is my perspective.
Click to expand...
We used to do all of them then the cardiologists took over the tee part too. Suits us fine, it was a pita and pay no good
They think they have secured some alternative funding, im not sure. Unfortunately theyre not very good at it and cant hold the image steady with one hand so they need another person to press the knobs. Its kind of comical.

Their echo techs wont go into the room, so they asked us to be their tech. We told em beat it. So they have no choice but have 2 cardiologists do the tee on top of the 3rd cardiologist doing the actual clip.

It gets even worse when some even weaker cardiologists attempt to do the tee, there can be as many as 4 or even 5 cardiologist with a fellow in a single clip case
 
That’s incredible, 2 cardiologists to do the imaging. Your health system must have piles of money to burn.
 
T-burglar said:
That’s incredible, 2 cardiologists to do the imaging. Your health system must have piles of money to burn.
Click to expand...
Honestly sometimes 4 for tee alone(1fellow). And they can only hold the probe the opposite way to how our ORs and hybrid rooms are setup so they have to turn their body and machine around to get any kind of image even a basic 4 chamber.

Its theatre. Bordering in insanity. They will soon realize how ****e mitraclip is and abandon it
 
PpfSuxTube said:
Honestly sometimes 4 for tee alone(1fellow). And they can only hold the probe the opposite way to how our ORs and hybrid rooms are setup so they have to turn their body and machine around to get any kind of image even a basic 4 chamber.

Its theatre. Bordering in insanity. They will soon realize how ****e mitraclip is and abandon it
Click to expand...
Funny, we had a cardiologist new to the structural side help out with a watchman recently. We do these in EP, already a cramped space.

At the end of the case, legit asked why we couldn't park the TEE machine on the patients right side.

:nono:
 
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