Journal of the American Society of Echocardiography
State-of-the-Art ReviewState of the Art: Transcatheter Edge-to-Edge Repair for Complex Mitral Regurgitation
Section snippets
MitraClip
The EVEREST II and COAPT clinical trials used the original MitraClip, which is no longer commercially available. The third-generation MitraClip system was released in 2018 and introduced improvements in catheter steering and positioning as well as two different clip sizes (NTR and XTR). Compared with the NTR, the XTR has longer arms (12 vs 9 mm) and longer grippers (9 vs 6 mm), with two additional rows of frictional elements (six vs four; Figure 1). These changes result in a grasping width of
Noncentral MR
The inclusion criteria in the EVEREST II trial specified that the primary regurgitant jet must originate from malcoaptation of the A2–P2 scallops.6 However, approximately one third of patients have noncentral MR jets, occasionally arising at the commissures, involving the extreme edges of the leaflets.18,19 In the initial US commercial experience, segments outside of A2–P2 were treated in 21.6% of patients,20 and A2 to P2 location of clip implantation was an independent predictor of residual
Degenerative MR with a Wide Flail Gap
The EVEREST II trial excluded patients with large flail, defined as a flail segment width ≥ 15 mm or flail gap ≥ 10 mm (Figure 5). However, treating a flail leaflet is a particularly important application of transcatheter therapy, as degenerative valve disease with flail is associated with excessive mortality risk in the elderly.26 The presence of a flail leaflet is a predictor of a greater acute improvement in mean LA pressure after MitraClip implantation,22 which is associated with better
Barlow's Disease
Barlow's disease represents a severe form of myxomatous MV prolapse34 involving multiple segments of both the anterior and posterior leaflet. The durability of surgical repair of a Barlow's valve can be suboptimal, and the risk for MR after repair is significantly greater than for posterior leaflet prolapse alone.35 Advanced surgical repair techniques such as neochord implantation and/or sliding MV annuloplasty are associated with lower rates of MR recurrence, but these rates are still not
Failed Surgical MV Repair
Surgical MV repair does not always provide a definitive long-term solution, even when performed at centers with high surgical volumes.38 The 10-year recurrence rate of moderate to severe MR ranges between 10% and 35% after surgical repair of degenerative MR, with a greater risk seen in patients with anterior leaflet and bileaflet pathology.39,40 Reoperation for a failed MV repair is associated with high rates of valve replacement as well as operative complications and mortality, particularly in
Hypertrophic Obstructive Cardiomyopathy
Percutaneous plication of the MV with the MitraClip has been used as an alternative treatment for symptomatic hypertrophic obstructive cardiomyopathy.48 Transcatheter edge-to-edge repair can reduce the duration and magnitude of systolic anterior motion (SAM) of the MV, thereby reducing the LVOT gradient as well as reducing the dynamic MR that is commonly seen.49 The plication restricts anterior motion of the MV, preventing or reducing SAM-septal contact and consequently leading to a decrease in
Acute MR and/or Cardiogenic Shock
Severe MR can be the cause of cardiogenic shock as well as the result of severe LV dysfunction associated with cardiogenic shock. EVEREST II excluded patients with recent myocardial infarction, LV dysfunction (LVEF < 25%), and LV dilation (LV end-systolic diameter > 55 mm). COAPT enrolled stable, ambulatory patients (New York Heart Association class IVA or less) with LVEFs ≥ 20% and LV end-systolic diameters < 70 mm; American Heart Association stage D heart failure was an exclusion criterion.
MR in the Setting of Severe Aortic Stenosis
Moderate to severe MR is observed in 20% to 74% of elderly patients undergoing surgical aortic valve replacement or transcatheter aortic valve replacement (TAVR).57,58 Current data do not provide definitive insight as to whether coexisting severe aortic stenosis and MR should be treated with combined or staged procedures and in what order.59, 60, 61 A “commonsense” algorithm has been suggested,62 emphasizing reassessment of MR severity after TAVR and optimization of medical treatment as well as
Limitations
Other pathologies and clinical conditions that were directly excluded from EVEREST and COAPT were shown to be feasible for percutaneous repair by MV edge-to-edge repair, including cleft mitral leaflets65 and mitral annular calcification.66 However, some reports are limited to single-operator experience, limiting generalizability, and publication bias toward favorable outcomes must be considered. A strong association exists between MitraClip procedural volume and outcomes. Data from the TVT
Conclusion
MR is a heterogeneous condition with several etiologies and anatomic variation. Ongoing experience and refinement of both device and imaging technologies have made percutaneous edge-to-edge MV repair a transformative technology that is feasible across several mitral pathologies. At many centers, use of the MitraClip has moved beyond the EVEREST paradigm, and patients with challenging anatomy at high surgical risk are successfully treated with percutaneous edge-to-edge repair. However, this
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Cited by (14)
Training Model for Special Competency in Echocardiographic Guidance of Structural Heart Disease Interventions: The Value of High-Volume Institutions
2023, Journal of Cardiothoracic and Vascular AnesthesiaComprehensive Training Model for Procedural Guidance of Transcatheter Mitral Valve Edge-to-Edge Repair: Divide and Conquer Approach
2023, Journal of Cardiothoracic and Vascular AnesthesiaReal-Time Multiplanar Reconstruction Imaging Using 3-Dimensional Transesophageal Echocardiography in Structural Heart Interventions
2023, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :For example, the intercommissural view plays a key role in device positioning, and its orthogonal ME LAX view is critical for clip arm orientation for conventional A2-P2 pathology. As the pathology localizes laterally or medially to A1-P1 or A3-P3, respectively, these 2 standard views become less helpful as the device clip arms will become out of plane.11 Using 3D live MPR in these situations allows for not only optimal imaging plane and device clip arm alignment, but also real-time confirmation of clip arm perpendicularity to the coaptation line in the accompanying short-axis view (Table 1, Panel 3).
3D Intracardiac Echocardiography in Mitral Transcatheter Edge-to-Edge Repair: When TEE Is Hard to Stomach
2022, JACC: Case ReportsCitation Excerpt :The patient was discharged 2 days post-procedure. Management of MR with TEER is reasonable for selected patients with moderate to severe secondary MR1 and appropriate anatomy.2,3 To understand mitral valve disease, anatomy, flow dynamics, and severity of regurgitation, comprehensive 2-dimensional (2D) or 3D TEE has become the gold-standard.4
Mitral Valve Prolapse—The Role of Cardiac Imaging Modalities
2022, Structural HeartVisualizing the Immediate Hemodynamic Impact of Successful Transcatheter Edge-to-Edge Repair of the Mitral Valve
2022, Journal of Cardiothoracic and Vascular Anesthesia
Dr. Price has received consulting fees and speaking honoraria from Abbott Vascular, AstraZeneca, Boston Scientific, Chiesi USA, Medtronic, and W.L. Gore Medical.