State-of-the-Art Review
State of the Art: Transcatheter Edge-to-Edge Repair for Complex Mitral Regurgitation

https://doi.org/10.1016/j.echo.2021.03.240Get rights and content

Highlights

  • MR is a heterogeneous condition with several etiologies and anatomic variations.

  • Echocardiography is important to assess if MR is primary or due to LV dysfunction.

  • Transcatheter edge-to-edge MV repair mimics surgery, creating a double-orifice valve.

  • Experience, imaging, and new devices allow for MV repair in complex mitral disorders.

  • Collaboration between the interventionalist and imager is key to treating complex MR.

Transcatheter edge-to-edge mitral valve repair has revolutionized the treatment of primary and secondary mitral regurgitation. The landmark EVEREST (Endovascular Valve Edge-to-Edge Repair Study) and COAPT (Clinical Outcomes Assessment of the MitraClip Percutaneous Therapy for High Surgical Risk Patients) trials included only clinically stable patients with favorable mitral valve anatomy for edge-to-edge repair. However, since its initial commercial approval in the United States, growing operator experience, device iterations, and improvements in intraprocedural imaging have led to an expansion in the use of transcatheter edge-to-edge repair to more complex mitral valve pathologies and clinical scenarios, many of which were previously considered contraindications for the procedure. Because patients with prohibitive surgical risk are often older and present with complex mitral valve disease, knowledge of the potential effectiveness, versatility, and technical approach to a broad range of anatomy is clinically relevant. In this review the authors examine the current experience with mitral valve transcatheter edge-to-edge repair in various pathologies and scenarios that go well beyond the EVEREST II trial inclusion criteria.

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

References (69)

  • D.S. Lim et al.

    Transcatheter valve repair for patients with mitral regurgitation: 30-day results of the CLASP study

    JACC Cardiovasc Interv

    (2019)
  • J.G. Webb et al.

    1-Year outcomes for transcatheter repair in patients with mitral regurgitation from the CLASP study

    JACC Cardiovasc Interv

    (2020)
  • R. Estevez-Loureiro et al.

    Echocardiographic and clinical outcomes of central versus noncentral percutaneous edge-to-edge repair of degenerative mitral regurgitation

    J Am Coll Cardiol

    (2013)
  • P. Sorajja et al.

    Initial experience with commercial transcatheter mitral valve repair in the United States

    J Am Coll Cardiol

    (2016)
  • A.K. Chhatriwalla et al.

    Institutional experience with transcatheter mitral valve repair and clinical outcomes: insights from the TVT Registry

    JACC Cardiovasc Interv

    (2019)
  • E. Avenatti et al.

    Percutaneous repair of severe eccentric mitral regurgitation due to medial commissural flail: challenges for imaging and intervention

    CASE (Phila)

    (2018)
  • I. Komatsu et al.

    Transcatheter mitral valve edge-to-edge repair with the new MitraClip XTR system for acute mitral regurgitation caused by papillary muscle rupture

    Can J Cardiol

    (2019)
  • E. Bahlmann et al.

    MitraClip implantation after acute ischemic papillary muscle rupture in a patient with prolonged cardiogenic shock

    Ann Thorac Surg

    (2015)
  • A.C. Anyanwu et al.

    Etiologic classification of degenerative mitral valve disease: Barlow’s disease and fibroelastic deficiency

    Semin Thorac Cardiovasc Surg

    (2007)
  • T.E. David et al.

    A comparison of outcomes of mitral valve repair for degenerative disease with posterior, anterior, and bileaflet prolapse

    J Thorac Cardiovasc Surg

    (2005)
  • W. Flameng et al.

    Durability of mitral valve repair in Barlow disease versus fibroelastic deficiency

    J Thorac Cardiovasc Surg

    (2008)
  • C. Grasso et al.

    Percutaneous mitral valve repair with the MitraClip system for severe mitral regurgitation in patients with surgical mitral valve repair failure

    J Am Coll Cardiol

    (2014)
  • D. Braun et al.

    Percutaneous edge-to-edge repair of recurrent severe mitral regurgitation after surgical mitral valve repair

    J Am Coll Cardiol

    (2017)
  • E. Avenatti et al.

    Percutaneous repair for recurrent mitral regurgitation after surgical repair: a MitraClip experience

    Structural Heart

    (2018)
  • H. Niikura et al.

    Transcatheter mitral valve repair of recurrent mitral regurgitation following mitral surgery

    JACC Cardiovasc Interv

    (2019)
  • B.S. Kanda et al.

    Leaflet-to-annuloplasty ring clipping for severe mitral regurgitation

    JACC Cardiovasc Interv

    (2016)
  • C.B. Nyman et al.

    Transcatheter mitral valve repair using the edge-to-edge clip

    J Am Soc Echocardiogr

    (2018)
  • P. Sorajja et al.

    First experience with percutaneous mitral valve plication as primary therapy for symptomatic obstructive hypertrophic cardiomyopathy

    J Am Coll Cardiol

    (2016)
  • R. Cheng et al.

    Percutaneous mitral repair for patients in cardiogenic shock requiring inotropes and temporary mechanical circulatory support

    JACC Cardiovasc Interv

    (2019)
  • M. Alkhouli et al.

    The feasibility of transcatheter edge-to-edge repair in the management of acute severe ischemic mitral regurgitation

    JACC Cardiovasc Interv

    (2017)
  • M. Adamo et al.

    Percutaneous edge-to-edge mitral valve repair for the treatment of acute mitral regurgitation complicating myocardial infarction: a single centre experience

    Int J Cardiol

    (2017)
  • C.R. Thompson et al.

    Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the SHOCK trial registry

    J Am Coll Cardiol

    (2000)
  • L. Nombela-Franco et al.

    Significant mitral regurgitation left untreated at the time of aortic valve replacement: a comprehensive review of a frequent entity in the transcatheter aortic valve replacement era

    J Am Coll Cardiol

    (2014)
  • K. Eudailey et al.

    MitraClip followed by surgical aortic valve replacement: hybrid techniques for regurgitant aortic and mitral valve disease

    Ann Thorac Surg

    (2016)
  • Cited by (14)

    • Real-Time Multiplanar Reconstruction Imaging Using 3-Dimensional Transesophageal Echocardiography in Structural Heart Interventions

      2023, Journal of Cardiothoracic and Vascular Anesthesia
      Citation 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 Reports
      Citation 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

    View all citing articles on Scopus

    Dr. Price has received consulting fees and speaking honoraria from Abbott Vascular, AstraZeneca, Boston Scientific, Chiesi USA, Medtronic, and W.L. Gore Medical.

    View full text