Percutaneous mitral valve repair: A new treatment for mitral regurgitation

Mitral valve disease affects more than 4 million people in the United States. The gold standard of treatment in these patients is surgical repair or replacement of the valve with a prosthesis. The MitraClip (Abbott Vascular, Menlo Park, CA) is a new technology, which offers an alternative to open surgical repair or replacement via a minimally invasive route. We present an evidence-based clinical update that provides an overview of this technology as it relates to managing patients with significant mitral regurgitation. This review article is particularly useful to noninterventional cardiologists and interventional cardiologists who will be managing patients with this novel technology in increased volumes over the next decade but who do not perform this procedure.     

Percutaneous mitral valve repair: a feasibility study in an ovine model of acute ischemic mitral regurgitation.

Annuloplasty is the cornerstone of surgical mitral valve repair. A percutaneous transvenous catheter-based approach for mitral valve repair was tested by placing a novel annuloplasty device in the coronary sinus of sheep with acute ischemic mitral regurgitation. Mitral regurgitation was reduced from 3-4+ to 0-1+ in all animals (P < 0.03). The annuloplasty functioned by reducing septal-lateral mitral annular diameter (30 +/- 2.1 mm preinsertion vs. 24 +/- 1.7 mm postinsertion; P < 0.03). These preliminary experiments demonstrate that percutaneous mitral annuloplasty is feasible. Further study is necessary to demonstrate long-term safety and efficacy of this novel approach.     

Percutaneous mitral valve annuloplasty for ischemic mitral regurgitation: First in man experience with a temporary implant

Objective : This study evaluated human feasibility and acute efficacy of a novel percutaneous transvenous mitral annuloplasty (PTMA?) device (Viacor) placed temporarily in the coronary sinus (CS): the implant allows in‐situ incremental adjustment to optimally reduce the anterior–posterior mitral annulus (MA) dimension, and improve leaflet co‐aptation and reducing mitral regurgitation (MR). Background : Surgical annuloplasty remains the standard treatment of severe ischemic MR but its application is limited by high morbidity and mortality. The effectiveness of PTMA device (Viacor) to reduce MR in the short‐term has been demonstrated in animals studies but not in humans. Methods : Symptomatic patients with ischemic MR graded 2+ to 4+ requiring surgical mitral annuloplasty were screened. Patients with any mitral leaflet or mitral apparatus abnormality were excluded. Preoperatively, under general anesthesia and transesophageal echocardiography guidance, a temporary PTMA device was placed via the right internal jugular or subclavian vein. Results : Four patients were studied. After device placement and adjustment, regurgitant volume was substantially reduced (45.5 ± 24.4 to 13.3 ± 7.3 ml) via MA anterior–posterior diameter reduction (40.75 ± 4.3 to 35.2 ± 1.6 mm) in 3 patients. In one patient, the PTMA device could not be deployed due to extreme angulated anatomy. Conclusions : PTMA in human is feasible and reduces ischemic MR (to grade 1+) by reducing MA anterior–posterior diameter. Temporary placement of the PTMA device may assist in the development of permanent implants and ensure optimal efficacy. © 2007 Wiley‐Liss, Inc.     

Left ventricular mechanics following restrictive mitral annuloplasty for functional mitral regurgitation: two-dimensional speckle tracking echocardiographic study

Background: Restrictive mitral annuloplasty (RMA) is widely employed for patients with functional mitral regurgitation (MR). Its improvement of left ventricular (LV) function has been demonstrated by only a gradual increase in LV ejection fraction (EF) in the chronic phase. However, the detailed evaluation of changes in LV function has not been fully elucidated in functional MR patients before and after RMA. Therefore, we performed two‐dimensional speckle tracking echocardiography (2D‐STE), which enables accurate evaluation of myocardial deformation and rotation that are undetectable by conventional echocardiography. Methods: We studied 13 patients (mean age 61 ± 10 years) with functional MR associated with cardiomyopathy undergoing RMA. In addition to conventional echocardiographic measurements, 2D‐STE was performed to measure peak systolic radial (RS), circumferential (CS), and longitudinal (LS) strains and twist before and 4 ± 2 weeks after surgery. LV twist was defined as the difference between the apical and basal rotations. Results: After RMA, EF and LS remained unchanged, but RS and CS were significantly improved at the mid‐LV (RS, 20.6 ± 10.8 vs 24.5 ± 11.6%; CS, ?9.6 ± 5.2 vs ?12.8 ± 5.6%) and at the apex (RS, 15.0 ± 12.2 vs 18.7 ± 8.6%; CS, ?4.4 ± 3.0 vs ?7.8 ± 4.8%). RS and CS were unchanged at the base. The apical and basal rotations changed significantly, from 3.5°± 0.7° to 9.2°± 2.1°, and ?2.1°± 0.7° to ?3.8°± 1.0°, respectively. Consequently, the LV twist increased significantly, from 5.6°± 1.0° to 13.0°± 1.9°. Conclusions: Radial and circumferential strains and LV twist increased significantly in the early postoperative period in functional MR patients after RMA and concomitant procedures. (Echocardiography 2012;29:445‐450)     

Superiority of mitral valve repair in surgery for degenerative mitral regurgitation

OBJECTIVES: We aimed to assess the influence of type of operation on outcomein degenerative mitral regurgitation. METHODS: We compared outcomes in 278 consecutive patients who underwentmitral valve repair (167 patients), replacement with subvalvularpreservation (22 patients) and without subvalvular preservation(89 patients) for degenerative mitral regurgitation. RESULTS: There was a trend towards lower mortality with repair and replacementwith subvalvular preservation compared to replacement withoutsubvalvular preservation. Thirty-day mortality was 1·2%vs 0·0% vs 4·7% (ns) respectively. Six-year survivalwas, respectively, 67·8±7·4% (P=0·088)vs 80·8±11·0% (P=0·25 vs 63·3±5·9%for all-cause death, 78·5±6·8% (P=0·063)vs 95·5±4·4% (P=0·092) vs 67·6±5·9%for all complication-related death and 80·5±6·9%(P=0·076) vs 100·0±0·0% (P=0·045)vs 72· ± 5·8% for complication-relateddeath due to myocardial failure. Multivariate analysis confirmedindependent beneficial effects from repair compared to replacementwithout subvalvular preservation on complication-related death(hazard ratio 0·42, P=0·010) and death from myocardialfailure (hazard ratio 0·40 P=0·014), and fromrepair compared to mechanical replacement on thromboembolism(hazard ratio 0·45, P=0·029) and anticoagulation-relatedhaemorrhage (hazard ratio 0·19, P=0·026). CONCLUSIONS: Mitral valve repair is superior to replacement. The greatestsurvival advantage is in reduced mortality from myocardial failure.Repair should be the operation of choice for degenerative mitralregurgitation.     

Recurrent mitral regurgitation late after annuloplasty for ischemic mitral regurgitation

In 106 patients who had mitral annuloplasty for ischemic mitral regurgitation (MR), 71 patients (67%) had satisfactory outcomes with <2+ MR (grade 0-4) throughout the follow-up period (44 ± 31 months), while 35 patients (33%) had significant recurrent MR (≥2+) late after annuloplasty (≥6 months) during the follow-up period (45 ± 30 months). Compared to those with recurrent MR, the success group had a significantly higher proportion of patients whose left ventricular (LV) ejection fraction (EF) stayed stable or increased over the follow-up period postoperatively (47/70 = 67% vs. 14/35 = 40%, P < 0.01). The success group had a higher proportion of patients whose LV end-systolic volume stayed stable or decreased (37/63 = 59% vs. 6/35 = 17%, P < 0.01) and lower LV sphericity in systole (0.46 ± 0.096 vs. 0.60 ± 0.10, P < 0.01). In conclusion, recurrent ischemic MR after annuloplasty is associated with increasing LV size, decreasing LVEF, and increasing sphericity of the LV.     

Redo MitraClip mitral valve repair after a late single leaflet detachment

Percutaneous mitral valve repair with the MitraClip^® (Abbott, Abbott Park, IL) can reduce mitral regurgitation (MR) and improve symptoms and quality of life in patients with severe mitral regurgitation. While this therapy is safe, there have been reports of single leaflet detachment where the MitraClip remains attached only to one leaflet of the mitral valve after deployment. Most of these cases occur within the first month of the procedure but there have been reports of late detachment occurring after this period. This case report describes a patient with severe functional MR who underwent an initial successful MitraClip procedure with implantation of two clips but subsequently developed late detachment of one clip. It also discusses the challenges and feasibility of performing a repeat MitraClip procedure in these patients. © 2013 Wiley Periodicals, Inc.     

Impact of concomitant tricuspid regurgitation on outcome after edge-to-edge mitral valve repair

Aims

To evaluate the impact of tricuspid regurgitation (TR) on echocardiographic and functional outcome after mitral valve transcatheter edge-to-edge-repair (M-TEER).

Methods and Results

A total of 740 patients underwent M-TEER at our center from 2010 to 2021. Patients were analyzed according to severity of concomitant TR at the time of M-TEER procedure: low-grade TR (grade ≤I [trace–mild], 279 patients [37.7%]), moderate TR (grade II, 170 patients [23.0%]) and high-grade TR (grade III-V [severe–torrential], 291 patients [39.3%]). Patients with moderate to high-grade TR had higher morbidity. Procedural success of M-TEER was achieved similarly in all groups (98.2% vs. 97.6% vs. 95.9%, p = 0.22). TR severity decreased rapidly and consistently after M-TEER to only 48.0% of high-grade TR patients after 3 months (p < 0.001) and to 46.8% after 12 months (p = 0.99). High-grade TR patients had significantly higher mortality (21.5% vs. 18.2% vs. 11.1%, p = 0.003) up to 12 months after M-TEER. However, high-grade TR did not independently predict mortality (HR 1.302, 95% CI 0.937–1.810; p = 0.116). Echocardiographic and functional outcome was similar in both secondary and primary MR patients.

Conclusions

High-grade concomitant TR did not independently predict adverse outcome following M-TEER. A wait-and-observe approach for these patients is reasonable.     

Percutaneous repair of severe mitral valve regurgitation secondary to chordae rupture in octogenarians using MitraClip

Objectives

The aim of this study was to assess feasibility and clinical effectiveness of the MitraClip device in octogenarians suffering from severe mitral valve regurgitation due to chordae rupture.

Background

The MitraClip procedure is a suitable technique in high‐risk surgical patients to achieve safe and effective percutaneous repair of mitral valve regurgitation. Octogenarians show cumulative risk and social aspects hindering mitral valve surgery. No data exists regarding the use of the MitraClip device in high‐risk octogenarians suffering from mitral valve chordae rupture.

Methods

Between October 2009 and March 2017 98 high‐risk octogenarians (society of thoracic surgeons score [STS]: 9.7% ± 0.8) with mitral valve prolapse and consecutively chordae rupture were treated with the MitraClip after interdisciplinary discussion.

Results

Successful mitral valve repair was achieved in 91% of the octogenarians. Repair of the mitral valve caused immediate and significant reduction of dyspnoea (NYHA class: 3.5 ± 0.4 vs 2.0 ± 0.3; P < 0.001), cardiac reverse remodeling (LVESD: 39 ± 0.8 vs 35 ± 0.8; P < 0.01) and amelioration of cardiac biomarkers (NTproBNP (4884 ± 52 ng/L vs 2473 ± 210 ng/L; P < 0.05,). Effects were stable over the 12 months observation period. None of our patients died intraprocedurally.

Conclusions

Percutaneous repair of chordae rupture is feasible and safe in high‐risk octogenarians. The MitraClip should be considered to repair severe mitral valve regurgitation due to mitral valve chordae rupture in high‐risk octogenarians after interdisciplinary discussion even facing a challenging anatomy.     

Pulmonary arterial pressure detects functional mitral stenosis after annuloplasty for primary mitral regurgitation: An exercise stress echocardiographic study

Introduction

The restrictive mitral valve annuloplasty (RMA) is the treatment of choice for degenerative mitral regurgitation (MR), but postoperative functional mitral stenosis remains a matter of debate. In this study, we sought to determine the impact of mitral stenosis on the functional capacity of patients.

Methods

In a cross‐sectional study, 32 patients with degenerative MR who underwent RMA using a complete ring were evaluated. All participants performed treadmill exercise test and underwent echocardiographic examinations before and after exercise.

Results

The patients’ mean age was 50.1 ± 12.5 years. After a mean follow‐up of 14.1 ± 5.9 months (6–32 months), the number of patients with a mitral valve peak gradient >7.5 mm Hg, a mitral valve mean gradient >3 mm Hg, and a pulmonary arterial pressure (PAP) ≥25 mm Hg at rest were 50%, 40.6%, and 62.5%, respectively. 13 patients (40.6%) had incomplete treadmill exercise test. All hemodynamic parameters were higher at peak exercise compared with at rest levels (all P < .05). The PAP at rest and at peak exercise as well as peak transmitral gradient at peak exercise were higher in patients with incomplete exercise compared with complete exercise test (all P < .05). The PAP at rest (a sensitivity and a specificity of 84.6% and 52.6%, respectively; area under the curve [AUC] = .755) and at peak exercise (a sensitivity and a specificity of 100% and 47.4%, respectively; AUC = .755) discriminated incomplete exercise test.

Conclusion

The RMA for degenerative MR was associated with a functional stenosis and the PAP at rest and at peak exercise discriminated low exercise capacity.     

Surgical timing for mitral valve regurgitation

Advances in diagnostic and surgical techniques in the management of mitral regurgitation have resulted in improved survival rates and clinical outcomes. Echocardiography is a valuable noninvasive diagnostic tool in the determination of the timing of surgical correction of mitral regurgitation. Improved surgical techniques, the growing role of mitral valve repair, low operative mortality rates, and improved long-term survival rates are important considerations for earlier surgical intervention in symptomatic patients and in asymptomatic patients with echocardiographic criteria of left ventricular dilatation. Intraoperative transesophageal echocardiography is very useful in mitral valve repair and valve replacement with preservation of chordal structures.     

应用Carpentier-Edwards生理环治疗退行性二尖瓣反流的二尖瓣成形术后的二尖瓣狭窄

Repair durability for degenerative mitral regurgitation is excellent. Although the main reason for reoperation is residual or recurrent regurgitation, Postoperative mitral stenosis is extremely rare.     

Mitral valve hemodynamic effects of percutaneous edge-to-edge repair with the MitraClip device for mitral regurgitation.

INTRODUCTION: The Endovascular Valve Edge-to-Edge REpair STudies (EVEREST) are investigating a percutaneous technique for edge-to-edge mitral valve repair with a repositionable clip. The effects on the mitral valve gradient (MVG) and mitral valve area (MVA) are not known. METHODS: Twenty seven patients with moderate to severe or severe mitral regurgitation (MR) were enrolled. Echocardiography was performed preprocedure, at discharge, and at 1, 6, and 12 months. Mean MVG was measured by Doppler and MVA by planimetry and pressure half-time, and evaluated in a central core laboratory. Pre- and postclip deployment, simultaneous left atrial/pulmonary capillary wedge and left ventricular pressures were obtained in eight patients. RESULTS: Three patients did not receive a clip, six patients had their clip(s) explanted by 6 months (none for mitral stenosis), and four were repaired with two clips. Results are notable for a slight increase in mean MVG by Doppler postclip deployment (1.79 +/- 0.89 to 3.31 +/- 2.09 mm Hg, P < 0.01) and an expected decrease in MVA by planimetry (6.49 +/- 1.61 to 4.46 +/- 2.14 cm(2), P < 0.001) and by pressure half time (4.35 +/- 0.98 to 3.01 +/- 1.42 cm(2), P < 0.05). There were no significant changes in hemodynamic parameters postclip deployment by direct pressure measurements. There was no change in MVA by planimetry from discharge to 12 months (3.90 +/- 1.90 to 3.79 +/- 1.54 cm(2), P = 0.78). CONCLUSIONS: Echocardiographic and hemodynamic measurements after percutaneous mitral valve repair with the MitraClip show an expected decrease in mitral valve area with no evidence of clinically significant mitral stenosis either immediately after clip deployment or after 12 months of follow-up.     

Early results after mitral valvuloplasty for pure mitral regurgitation

In this study we present the results of 105 consecutive patientswith pure mitral regurgitation who underwent surgical treatment.In all patients mitral regurgitation was associated with mitralvalve prolapse: 54 patients underwent mitral valvuloplasty and51 patients mitral valve replacement. Clinical assessment and echocardiography were used as follow-upcriteria at one year after surgery. After mitral valvuloplasty,NYH A decreased from 2.7±0.8 to 1.1±0.7 (P<0.01)and workload capacity increased from 65±28% to 96±25%(P<0.001); left endsystolic atrial dimension and enddiastolicdimension decreased from 6.2±0.8 to 4.8±1.2 cm(P<0.001) and from 7.2±1.3 to 5.9±0.8 cm (P<0.01);ventricular contraction fraction did not change significantly. After mitral valve replacement, clinical and echocardiographicimprovement was significant but less remarkable than after valvuloplasty;ventricular contraction fraction fell from 39±7% to 29±8%in contrast to patients undergoing mitral valvuloplasty in whomno significant change occurred. Complications were rare in both groups though only a minorityof patients undergoing mitral valvuloplasty received anticoagulants.We conclude that mitral valvuloplasty in patients with puremitral regurgitation associated with mitral valve prolapse givesexcellent results, particularly regarding left ventricular functionwhen compared with the patients after mitral valve replacement.     

Early results after mitral valvuloplasty for pure mitral regurgitation

In this study we present the results of 105 consecutive patientswith pure mitral regurgitation who underwent surgical treatment.In all patients mitral regurgitation was associated with mitralvalve prolapse: 54 patients underwent mitral valvuloplasty and51 patients mitral valve replacement. Clinical assessment and echocardiography were used as follow-upcriteria at one year after surgery. After mitral valvuloplasty,NYH A decreased from 2.7±0.8 to 1.1±0.7 (P<0.01)and workload capacity increased from 65±28% to 96±25%(P<0.001); left endsystolic atrial dimension and enddiastolicdimension decreased from 6.2±0.8 to 4.8±1.2 cm(P<0.001) and from 7.2±1.3 to 5.9±0.8 cm (P<0.01);ventricular contraction fraction did not change significantly. After mitral valve replacement, clinical and echocardiographicimprovement was significant but less remarkable than after valvuloplasty;ventricular contraction fraction fell from 39±7% to 29±8%in contrast to patients undergoing mitral valvuloplasty in whomno significant change occurred. Complications were rare in both groups though only a minorityof patients undergoing mitral valvuloplasty received anticoagulants.We conclude that mitral valvuloplasty in patients with puremitral regurgitation associated with mitral valve prolapse givesexcellent results, particularly regarding left ventricular functionwhen compared with the patients after mitral valve replacement.