Transcatheter Therapies for Mitral Regurgitation

Predictive Factors of Cardiac Mortality Following TEER in Patients with Secondary Mitral Regurgitation

Background: Transcatheter edge-to-edge mitral valve repair (TEER) has emerged as a viable approach to addressing substantial secondary mitral regurgitation. In the contemporary landscape where ultimate heart failure-specific therapies, such as cardiac replacement modalities, are available, prognosticating a high-risk cohort susceptible to early cardiac mortality post-TEER is pivotal for formulating an effective therapeutic regimen. Methods: Our study encompassed individuals with secondary mitral regurgitation and chronic heart failure enlisted in the multi-center (Optimized CathEter vAlvular iNtervention (OCEAN)-Mitral registry. We conducted an assessment of baseline variables associated with cardiac death within one year following TEER. Results: Amongst the 1517 patients (median age: 78 years, 899 males), 101 experienced cardiac mortality during the 1-year observation period after undergoing TEER. Notably, a history of heart failure-related admissions within the preceding year, utilization of intravenous inotropes, and elevated plasma B-type natriuretic peptide levels emerged as independent prognosticators for the primary outcome (p < 0.05 for all). Subsequently, we devised a novel risk-scoring system encompassing these variables, which significantly stratified the cumulative incidence of the 1-year primary outcome (16%, 8%, and 4%, p < 0.001). Conclusions: Our study culminated in the development of a new risk-scoring system aimed at predicting 1-year cardiac mortality post-TEER.

Real-time 3D-3D image fusion of CTA/CBCT roadmap fluoroscopy in the transcatheter mitral intervention

Absence of periprocedural visualization of three-dimensional (3D) left heart anatomy and its surrounding structures in fluoroscopy may reduce the rate of successful transcatheter mitral valve repair. We proposed a multimodal imaging strategy based on 3D computed tomography (CT) angiography and 3D cone beam CT fusion images, which enabled real-time visual inspection of 3D cardiac structures on fluoroscopy, to optimize transcatheter mitral intervention. This new image fusion technology, together with standard transesophageal echocardiography guidance, improved the efficiency and safety of the procedure, and could be considered as a new workflow for transcatheter mitral valve intervention.

Mitral regurgitation: lessons learned from COAPT and MITRA-Fr

Recent studies about percutaneous treatment of secondary mitral regurgitation (MR) underlined the importance of left ventricular geometry and features of mitral valve as determinants of procedural and long-term success. Guideline-directed medical therapy (GDMT), transcatheter mitral valve treatment (TMVT) and surgical procedures (mitral valve replacement, mitral valve repair at level of the annulus or subvalvular apparatus) have been extensively evaluated but not adequately compared in current clinical studies. A detailed analysis of the results of the study about transcatheter mitral valve repair would allow to evaluate the safety and effectiveness of such procedure and would provide potential indications for improving the quality of percutaneous and surgical repair in patients with moderate-to-severe secondary MR. Patients with proportionate MR (i.e., MR severity is proportional to the amount of left ventricular dilatation) are prone to respond to the optimization of medical therapy, while patients with disproportionate MR (i.e., MR severity is disproportionately higher than predicted by left ventricular dilatation, with high EROA and small left ventricle) are likely to benefit from additional repair. The identification of specific subpopulation of "high responders", based on the anatomic characteristics of the mitral valve and the relative dimensions of the annulus, the regurgitation and the left ventricle, can also apply to medical therapy. However, some pivotal component of MR (such as the symmetry of tethering and the differences in biomechanical features of leaflets) are not adequately investigated in current studies and warrant further evaluation.

Characteristics and outcomes of patients with normal left atrial pressure undergoing transcatheter mitral valve repair

Objective

A subset of patients at the time of transcatheter mitral valve repair (TMVR) will have normal left atrial pressure (LAP) (<13 mm Hg) despite having severe mitral regurgitation (MR). The goal of this study was to determine clinical characteristics and outcomes in patients with normal LAP undergoing TMVR.

Methods

A single-centre retrospective cohort of consecutive patients who underwent transcatheter edge-to-edge mitral valve clip and continuous LAP monitoring between 5/1/2014 and 5/1/2018 was analysed. One-year mortality was compared by Kaplan–Meier survival curves. Multivariable analysis was performed to identify predictors of normal LAP and 1 year mortality.

Results

Of the 204 patients undergoing TMVR, 65% were men and the mean age was 81. Of these patients, 31 (15%) had normal LAP (mean LAP 10.5 mm Hg, mean V wave 16.5 mm Hg) and 173 had elevated LAP (mean LAP 19 mm Hg, mean V wave 32.5 mm Hg). The prevalence of severe MR was not different between groups, although the normal LAP group had significantly lower effective regurgitant orifice area and regurgitant volume. Other notable baseline characteristics including prior cardiac surgery, atrial fibrillation, hypertension, diabetes, congestive heart failure, body mass index, mechanism of MR and ejection fraction were similar between groups. However, there was an increased prevalence of chronic lung disease (CLD) (45.2% vs 17.3%, p<0.001) in the normal LAP group. On multivariate analysis, the only significant predictor of normal LAP was the presence of CLD (OR 4.79 (1.83–12.36), p=0.001) and 1-year mortality was significantly higher in the normal LAP group (32.3% vs 12.7%, p=0.006). After adjustment for comorbidities, normal LAP was no longer a predictor of 1-year mortality (RR 1.62 (0.64–4.06), p=0.32); however, CLD (RR 3.44 (1.37–8.67), p=0.01) remained a statistically significant predictor.

Conclusion

Normal LAP at the time of TMVR is associated with a higher incidence of CLD which independently predicts increased 1-year mortality. In patients with CLD and apparently severe MR, measurement of LAP may help identify those with lower likelihood of benefit from TMVR.

Antiplatelet therapy in valvular and structural heart disease interventions

Transcatheter interventions for valvular and structural heart diseases are rapidly expanding due to greater operators' experience and development of new generation devices associated with increased procedural safety. They represent the standard strategy for patients with prohibitive risk for open surgery. These procedures are associated with a significant occurrence of both thrombotic and bleeding complications, thus in this setting, even more than in other percutaneous procedures, the balance between thrombotic and bleeding risk is critical. This review describes the current data available on the antithrombotic management of patients undergoing transcatheter aortic valve implantation (TAVI), percutaneous mitral valve repair with the MitraClip system, percutaneous left atrial appendage occlusion and percutaneous patent foramen ovale (PFO)/atrial septal defects (ASD) closure.

2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways

Mitral regurgitation (MR) is a complex valve lesion that can pose significant management challenges for the cardiovascular clinician. This Expert Consensus Document emphasizes that recognition of MR should prompt an assessment of its etiology, mechanism, and severity, as well as indications for treatment. A structured approach to evaluation based on clinical findings, precise echocardiographic imaging, and when necessary, adjunctive testing, can help clarify decision making. Treatment goals include timely intervention by an experienced heart team to prevent left ventricular dysfunction, heart failure, reduced quality of life, and premature death.

Transapical mitral valve implantation after unclipping of a MitraClip: a glimpse into the future and treatment considerations in mitral regurgitation

AIMS

Transcatheter mitral valve implantation (TMVI) is a novel approach that may enable a less invasive effective reduction of mitral regurgitation (MR). A limitation of the MitraClip is that definitive implantation of a clip precludes future therapy with TMVI. The purpose of this paper is to describe contemporary treatment considerations in patients with mitral valve regurgitation.

METHODS AND RESULTS

In this report we describe an attempted MitraClip implantation which resulted in no reduction of MR severity. There was a consensus that additional clips would probably not be effective. MitraClip implantation was therefore abandoned and the clip was removed, allowing subsequent successful TMVI with the Tiara™ system three weeks later. Echocardiography revealed secure seating of the prosthesis with good mitral valve function, trivial paravalvular leakage and transvalvular gradient of 3 mmHg. The patient recovered rapidly and was discharged four days post implant.

CONCLUSIONS

The clinical approach towards high-risk patients with significant MR may change in the next few years. In selected patients, in whom an initial attempt with MitraClip implantation results in only limited efficacy, the clip may be retrieved during the index procedure to allow subsequent TMVI.

Valvular heart disease and postoperative considerations

Despite increasing trends in catheter-based cardiac surgical procedures, more than 278 000 Americans had traditional cardiac surgery in 2013. Of those surgical procedures, approximately 133 000 involved valvular repair or replacement. Aortic valve replacement was by far the most common valvular operation, followed by mitral valve repair or replacement. This review article will discuss characteristics of valvular pathologies and postoperative concerns for each the 4 cardiac valves.