Advertisement
Canadian Journal of Cardiology

Transcatheter Repair of the Mitral Valve: Relevant Pathophysiology, Investigation, and Management

Published:March 18, 2021DOI:https://doi.org/10.1016/j.cjca.2021.03.010

      Abstract

      Mitral regurgitation (MR) is a common condition causing significant morbidity and mortality in the Western world. Although surgical therapy has developed over 5 decades to provide solutions, only a minority of patients undergo surgery. The last decade has seen the emergence and application of multiple transcatheter techniques in attempts to address this undertreated population with the large clinical experience of MitraClip providing the most insight. Clear understanding of the pathophysiology of different MR types as well as the role of particularly secondary MR on patient's clinical syndrome allow for better prediction as to which patient subgroups will benefit from different repair techniques or intervention at all. Most of the techniques are based on surgical technique and are applied as single-device/technique solutions, whether leaflet, chordal, or annular solutions, but with broadening experience, combination therapies are likely to find a place in creating a more complete and surgical-like solution.

      Résumé

      L'insuffisance mitrale (RM) est une affection courante qui entraîne une morbidité et une mortalité importantes dans le monde occidental. Bien que les traitements chirurgicaux se soient développés au cours des cinq dernières décennies pour y apporter des solutions, seule une minorité de patients est opérée. La dernière décennie a vu l'émergence et la mise en œuvre de nombreuses techniques de transcathéterisme pour tenter de soigner cette population sous-traitée, et la vaste expérience clinique du MitraClip en apporte le meilleur aperçu. Une compréhension claire de la pathophysiologie des différents types de IM ainsi que du rôle d'une IM secondaire notamment sur le syndrome clinique du patient permet de mieux prédire quels sous-groupes de patients bénéficieront de différentes techniques de réparation ou d'une intervention en tant que telle. La plupart des techniques sont basées sur une méthode chirurgicale et sont appliquées comme des solutions à dispositif/technique unique, qu'il s'agisse de solutions ciblant les feuillets, les cordages ou l'anneau mitral, mais avec l'élargissement de l'expérience acquise, les thérapies combinées sont susceptibles de trouver une place dans l'élaboration d'une solution plus complète et de type chirurgical.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Nkomo VT
        • Gardin JM
        • Skelton TN
        • et al.
        Burden of valvular heart diseases: a population-based study.
        Lancet. 2006; 368: 1005-1011
        • Dziadzko V
        • Clavel MA
        • Dziadzko M
        • et al.
        Outcome and undertreatment of mitral regurgitation: a community cohort study.
        Lancet. 2018; 391: 960-969
        • Otto CM
        • Nishimura RA
        • Bonow RO
        • et al.
        2020 ACC/AHA guideline for the management of patients with valvular heart disease.
        J Am Coll Cardiol. 2021; 77: e24-197
        • Mirabel M
        • Iung B
        • Baron G
        • et al.
        What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery?.
        Eur Heart J. 2007; 28: 1358-1365
        • Goel SS
        • Bajaj N
        • Aggarwal B
        • et al.
        Prevalence and outcomes of unoperated patients with severe symptomatic mitral regurgitation and heart failure: comprehensive analysis to determine the potential role of MitraClip for this unmet need.
        J Am Coll Cardiol. 2014; 63: 185-186
        • Feldman T
        • Foster E
        • Glower DG
        • et al.
        Percutaneous repair or surgery for mitral regurgitation.
        N Engl J Med. 2011; 364: 1395-1406
        • Obadia JF
        • Messika-Zeitoun D
        • Leurent G
        • et al.
        Percutaneous repair or medical treatment for secondary mitral regurgitation.
        N Engl J Med. 2018; 379: 2297-2306
        • Stone GW
        • Lindenfeld JA
        • Abraham WT
        • et al.
        Transcatheter mitral-valve repair in patients with heart failure.
        N Engl J Med. 2018; 379: 2307-2318
        • Praz F
        • Spargias K
        • Chrissoheris M
        • et al.
        Compassionate use of the PASCAL transcatheter mitral valve repair system for patients with severe mitral regurgitation: a multicentre, prospective, observational, first-in-man study.
        Lancet. 2017; 390: 773-780
        • Siminiak T
        • Wu JC
        • Haude M
        • et al.
        Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN trial.
        Eur J Heart Fail. 2012; 14: 931-938
        • Miller M
        • Thourani VH
        • Whisenant B
        The Cardioband transcatheter annular reduction system.
        Ann Cardiothorac Surg. 2018; 7: 16545
        • Rogers JH
        • Boyd WD
        • Smith TW
        • Bolling SF.
        Early experience with Millipede IRIS transcatheter mitral annuloplasty.
        Ann Cardiothorac Surg. 2018; 7: 16543
        • Schueler R
        • Nickenig G.
        The Mitralign: strategies for optimal patient selection and optimised results.
        EuroIntervention. 2016; 12: Y67-Y69
        • Colli A
        • Adams D
        • Fiocco A
        • et al.
        Transapical NeoChord mitral valve repair.
        Ann Cardiothorac Surg. 2018; 7: 16555
        • Gammie JS
        • Wilson P
        • Bartus K
        • et al.
        Transapical beating-heart mitral valve repair with an expanded polytetrafluoroethylene cordal implantation device.
        Circulation. 2016; 134: 189-197
        • Colli A
        • Raanani E
        • Cobiella J
        • et al.
        Transapical and transfemoral combined mitral valve repair with annular and leaflet therapies.
        Ann Thorac Surg. 2020; 110: e221-e223
        • Carpentier A
        Cardiac valve surgery: the “French correction.
        J Thorac Cardiovasc Surg. 1983; 86: 323-337
        • Ruiz JMM
        • Galderisi M
        • Buonauro A
        • et al.
        Overview of mitral regurgitation in Europe: results from the European Registry of Mitral Regurgitation (EuMiClip).
        Eur Heart J Cardiovasc Imaging. 2018; 19: 503-507
        • Thomas KL
        • Jackson LR
        • Shrader P
        • et al.
        Prevalence, characteristics, and outcomes of valvular heart disease in patients with atrial fibrillation: insights from the ORBIT-AF (Outcomes Registry for Better Informed Treatment for Atrial Fibrillation).
        J Am Heart Assoc. 2017; 6e006475
        • Kajimoto K
        • Sato N
        • Takano T
        Functional mitral regurgitation at discharge and outcomes in patients hospitalized for acute decompensated heart failure with a preserved or reduced ejection fraction.
        Eur J Heart Fail. 2016; 18: 1051-1059
        • Gertz ZM
        • Raina A
        • Saghy L
        • et al.
        Evidence of atrial functional mitral regurgitation due to atrial fibrillation: Reversal with arrhythmia control.
        J Am Coll Cardiol. 2011; 58: 1474-1481
        • Kotecha D
        • Lam CSP
        • van Veldhuisen DJ
        • et al.
        Heart failure with preserved ejection fraction and atrial fibrillation: vicious twins.
        J Am Coll Cardiol. 2016; 68: 2217-2228
        • Deferm S
        • Bertrand PB
        • Verbrugge FH
        • et al.
        Atrial functional mitral regurgitation: JACC review topic of the week.
        J Am Coll Cardiol. 2019; 73: 2465-2476
        • Zoghbi WA
        • Adams D
        • Bonow RO
        • et al.
        Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance.
        J Am Soc Echocardiogr. 2017; 30: 303-371
        • Kahlert P
        • Plicht B
        • Schenk IM
        • et al.
        Direct assessment of size and shape of noncircular vena contracta area in functional versus organic mitral regurgitation using real-time three-dimensional echocardiography.
        J Am Soc Echocardiogr. 2008; 21: 912-921
        • Altiok E
        • Hamada S
        • Van Hall S
        • et al.
        Comparison of direct planimetry of mitral valve regurgitation orifice area by three-dimensional transesophageal echocardiography to effective regurgitant orifice area obtained by proximal flow convergence method and vena contracta area determined by color.
        Am J Cardiol. 2011; 107: 452-458
        • Chen C
        • Thomas JD
        • Anconina J
        • et al.
        Impact of impinging wall jet on color doppler quantification of mitral regurgitation.
        Circulation. 1991; 84: 712-720
        • Ben Zekry S
        • Nagueh SF
        • Little SH
        • et al.
        Comparative accuracy of two- and three-dimensional transthoracic and transesophageal echocardiography in identifying mitral valve pathology in patients undergoing mitral valve repair: initial observations.
        J Am Soc Echocardiogr. 2011; 24: 1079-1085
        • Uretsky S
        • Supariwala A
        • Nidadovolu P
        • et al.
        Quantification of left ventricular remodeling in response to isolated aortic or mitral regurgitation.
        J Cardiovasc Magn Reson. 2010; 12: 32
        • Delgado V
        • Tops LF
        • Schuijf JD
        • et al.
        Assessment of mitral valve anatomy and geometry with multislice computed tomography.
        JACC Cardiovasc Imaging. 2009; 2: 556-565
        • van Mieghem NM
        • Rodríguez-Olivares R
        • Ren BC
        • et al.
        Computed tomography optimised fluoroscopy guidance for transcatheter mitral therapies.
        EuroIntervention. 2016; 11: 1428-1431
        • Sündermann SH
        • Biaggi P
        • Grünenfelder J
        • et al.
        Safety and feasibility of novel technology fusing echocardiography and fluoroscopy images during MitraClip interventions.
        EuroIntervention. 2014; 9: 1210-1216
        • Bonow RO
        • O'Gara PT
        • Adams DH
        • et al.
        2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Solution Set Oversight Committee.
        J Am Coll Cardiol. 2020; 75: 2236-2270
        • David TE
        • Armstrong S
        • McCrindle BW
        • Manlhiot C.
        Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease.
        Circulation. 2013; 127: 1485-1492
        • Gillinov AM
        • Tantiwongkosri K
        • Blackstone EH
        • et al.
        Is prosthetic anuloplasty necessary for durable mitral valve repair?.
        Ann Thorac Surg. 2009; 88: 76-82
        • De Bonis M
        • Lapenna E
        • Maisano F
        • et al.
        Long-term results (≤18 years) of the edge-to-edge mitral valve repair without annuloplasty in degenerative mitral regurgitation implications for the percutaneous approach.
        Circulation. 2014; 130: S19-S24
        • Condado JA
        • Acquatella H
        • Rodriguez L
        • et al.
        Percutaneous edge-to-edge mitral valve repair: 2-year follow-up in the first human case.
        Catheter Cardiovasc Interv. 2006; 67: 323-325
        • Alfieri O
        • Maisano F
        • De Bonis M
        • et al.
        The double-orifice technique in mitral valve repair: a simple solution for complex problems.
        J Thorac Cardiovasc Surg. 2001; 122: 674-681
        • Feldman T
        • Kar S
        • Rinaldi M
        • et al.
        Percutaneous mitral repair with the MitraClip system. safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge Repair Study) cohort.
        J Am Coll Cardiol. 2009; 54: 686-694
        • Altiok E
        • Hamada S
        • Brehmer K
        • et al.
        Analysis of procedural effects of percutaneous edge-to-edge mitral valve repair by 2D and 3D echocardiography.
        Circ Cardiovasc Imaging. 2012; 5: 748-755
        • Weinmann K
        • Markovic S
        • Rottbauer W
        • Keßler M.
        First experience with the MitraClip XTR device for extensive mitral valve prolapse (Barlow's disease).
        EuroIntervention. 2018; 14: e1276-e1277
        • Attizzani GF
        • Ohno Y
        • Capodanno D
        • et al.
        Extended use of percutaneous edge-to-edge mitral valve repair beyond EVEREST (Endovascular Valve Edge-to-Edge Repair) criteria.
        JACC Cardiovasc Interv. 2015; 8: 74-82
        • Chhatriwalla AK
        • Vemulapalli S
        • Holmes DR
        • et al.
        Institutional experience with transcatheter mitral valve repair and clinical outcomes: insights from the TVT Registry.
        JACC Cardiovasc Interv. 2019; 12: 1342-1352
        • Feldman T
        • Kar S
        • Elmariah S
        • et al.
        Randomized comparison of percutaneous repair and surgery for mitral regurgitation 5-year results of EVEREST II.
        J Am Coll Cardiol. 2015; 66: 2844-2854
        • Grayburn PA
        • Sannino A
        • Packer M.
        Proportionate and disproportionate functional mitral regurgitation: a new conceptual framework that reconciles the results of the MITRA-FR and COAPT TRIALS.
        JACC Cardiovasc Imaging. 2019; 12: 353-362
        • Adamo M
        • Cani DS
        • Gavazzoni M
        • et al.
        Impact of disproportionate secondary mitral regurgitation in patients undergoing edge-to-edge percutaneous mitral valve repair.
        EuroIntervention. 2020; 16: 413-420
        • Frea S
        • Pidello MD S
        • Boretto MD P
        • et al.
        Disproportionate functional mitral regurgitation predicts a favourable response after MitraClip implant in patients with advanced heart failure. Real-world evidence of a new conceptual framework.
        Int J Cardiol. 2021; 323: 208-212
        • Adamo M
        • Godino C
        • Giannini C
        • et al.
        Left ventricular reverse remodelling predicts long-term outcomes in patients with functional mitral regurgitation undergoing MitraClip therapy: results from a multicentre registry.
        Eur J Heart Fail. 2019; 21: 196-204
        • Papadopoulos K
        • Ikonomidis I
        • Chrissoheris M
        • et al.
        MitraClip and left ventricular reverse remodelling: a strain imaging study.
        ESC Heart Fail. 2020; 7: 1409-1418
        • Frangieh AH
        • Gruner C
        • Mikulicic F
        • et al.
        Impact of percutaneous mitral valve repair using the MitraClip system on tricuspid regurgitation.
        EuroIntervention. 2016; 11: e1680-e1686
        • Hünlich M
        • Lubos E
        • Beuthner BE
        • et al.
        Acute and long-term hemodynamic effects of MitraClip implantation on a preexisting secondary right heart failure.
        Biomed Res Int. 2018; 20186817832
        • Ledwoch J
        • Fellner C
        • Hoppmann P
        • et al.
        Impact of transcatheter mitral valve repair using MitraClip on right ventricular remodeling.
        Int J Cardiovasc Imaging. 2020; 36: 811-819
        • Ledwoch J
        • Nommensen A
        • Keelani A
        • et al.
        Impact of transcatheter mitral valve repair on ventricular arrhythmias.
        Europace. 2019; 9: 1385-1391
        • Benito-González T
        • Estévez-Loureiro R
        • Garrote-Coloma C
        • et al.
        Effect of successful edge-to-edge mitral valve repair on ventricular arrhythmic burden in patients with functional mitral regurgitation and implantable cardiac devices.
        Am J Cardiol. 2019; 124: 1113-1119
        • Stone GW
        • Adams DH
        • Abraham WT
        • et al.
        Clinical trial design principles and end point definitions for transcatheter mitral valve repair and replacement: part 2: end point definitions: a consensus document from the Mitral Valve Academic Research Consortium.
        J Am Coll Cardiol. 2015; 66: 308-321
        • Maisano F
        • Franzen O
        • Baldus S
        • et al.
        Percutaneous mitral valve interventions in the real world: Early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe.
        J Am Coll Cardiol. 2013; 62: 1052-1061
        • Nickenig G
        • Estevez-Loureiro R
        • Franzen O
        • et al.
        Percutaneous mitral valve edge-to-edge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011-2012 pilot European Sentinel Registry.
        J Am Coll Cardiol. 2014; 62: 875-884
        • Kalbacher D
        • Schäfer U
        • RSv Bardeleben
        • et al.
        Long-term outcome, survival and predictors of mortality after MitraClip therapy: results from the German Transcatheter Mitral Valve Interventions (TRAMI) registry.
        Int J Cardiol. 2019; 277: 35-41
        • Buzzatti N
        • Denti P
        • La Canna G
        • et al.
        Does implantation of a single clip provide reliable durability after transcatheter mitral repair.
        Eur J Cardiothorac Surg. 2017; 52: 137-142
        • Puls M
        • Huenlich M
        • Boekstegers P
        • et al.
        Implantation of one versus two MitraClips in the German TRAMI registry: is more always better?.
        Catheter Cardiovasc Interv. 2020; 96: e360-e368
        • Eggebrecht H
        • Schelle S
        • Puls M
        • et al.
        Risk and outcomes of complications during and after MitraClip implantation: experience in 828 patients from the German Transcatheter Mitral Valve Interventions (TRAMI) registry.
        Catheter Cardiovasc Interv. 2015; 86: 728-735
        • Neuss M
        • Schau T
        • Isotani A
        • et al.
        Elevated mitral valve pressure gradient after mitraclip implantation deteriorates long-term outcome in patients with severe mitral regurgitation and severe heart failure.
        JACC Cardiovasc Interv. 2017; 10: 931-939
        • Adamo M
        • Curello S
        • Chiari E
        • 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; 234: 53-57
        • Haberman D
        • Taramasso M
        • Czarnecki A
        • et al.
        Salvage MitraClip in severe secondary mitral regurgitation complicating acute myocardial infarction: data from a multicentre international study.
        Eur J Heart Fail. 2019; 21: 1161-1164
        • Estévez-Loureiro R
        • Adamo M
        • Arzamendi D
        • et al.
        Transcatheter mitral valve repair in patients with acute myocardial infarction: Insights from the European Registry of MitraClip in Acute Mitral Regurgitation Following an Acute Myocardial Infarction (EREMMI).
        EuroIntervention. 2020; 15: 1248-1250
        • Kovach CP
        • Bell S
        • Kataruka A
        • Reisman M
        • Don C.
        Outcomes of urgent/emergent transcatheter mitral valve repair (MitraClip): a single center experience.
        Catheter Cardiovasc Interv. 2020; 97: e402-e410
        • Papadopoulos K
        • Chrissoheris M
        • Nikolaou I
        • Spargias K.
        Edge-to-edge mitral valve repair for acute mitral valve regurgitation due to papillary muscle rupture: a case report.
        Eur Heart J Case Rep. 2019; 3: ytz001
        • Komatsu I
        • Cohen EA
        • Cohen GN
        • Czarnecki A.
        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; 35 (1604.e5-7)
        • Lim DS
        • Kar S
        • Spargias K
        • et al.
        Transcatheter valve repair for patients with mitral regurgitation: 30-day results of the CLASP study.
        JACC Cardiovasc Interv. 2019; 12: 1369-1378
        • Barth S
        • Hautmann MB
        • Arvaniti E
        • et al.
        Mid-term hemodynamic and functional results after transcatheter mitral valve leaflet repair with the new PASCAL device.
        Clin Res Cardiol. 2021; 110: 628-639
        • Lipiecki J
        • Siminiak T
        • Sievert H
        • et al.
        Coronary sinus-based percutaneous annuloplasty as treatment for functional mitral regurgitation: the TITAN II trial.
        Open Heart. 2016; 3e000411
        • Witte KK
        • Lipiecki J
        • Siminiak T
        • et al.
        The REDUCE FMR trial: a randomized sham-controlled study of percutaneous mitral annuloplasty in functional mitral regurgitation.
        JACC Heart Fail. 2019; 7: 945-955
        • Messika-Zeitoun D
        • Nickenig G
        • Latib A
        • et al.
        Transcatheter mitral valve repair for functional mitral regurgitation using the Cardioband system: 1 year outcomes.
        Eur Heart J. 2019; 40: 466-472
        • Nickenig G
        • Schueler R
        • Dager A
        • et al.
        Treatment of chronic functional mitral valve regurgitation with a percutaneous annuloplasty system.
        J Am Coll Cardiol. 2016; 67: 2927-2936
        • Colli A
        • Manzan E
        • Aidietis A
        • et al.
        An early European experience with transapical off-pump mitral valve repair with NeoChord implantation.
        Eur J Cardiothorac Surg. 2018; 54: 460-466
        • Colli A
        • Besola L
        • Montagner M
        • et al.
        Prognostic impact of leaflet-to-annulus index in patients treated with transapical off-pump echo-guided mitral valve repair with NeoChord implantation.
        Int J Cardiol. 2018; 257: 235-237
        • von Bardeleben RS
        • Colli A
        • Schulz E
        • et al.
        First in human transcatheter COMBO mitral valve repair with direct ring annuloplasty and neochord leaflet implantation to treat degenerative mitral regurgitation: Feasibility of the simultaneous toolbox concept guided by 3D echo and computed tomography fu.
        Eur Heart J. 2018; 39: 1314-1315
        • Gammie JS
        • Bartus K
        • Gackowski A
        • et al.
        Safety and performance of a novel transventricular beating heart mitral valve repair system: 1-year outcomes.
        Eur J Cardiothorac Surg. 2021; 59: 199-206
        • Benjamin EJ
        • Blaha MJ
        • Chiuve SE
        • et al.
        Heart disease and stroke statistics—2017 update: a report from the American Heart Association.
        Circulation. 2017; 135: e146-e603
        • El Sabbagh A
        • Reddy YNV
        • Nishimura RA
        Mitral valve regurgitation in the contemporary era: insights into diagnosis, management, and future directions.
        JACC Cardiovasc Imaging. 2018; 11: 628-643
        • Rogers JH
        • Boyd WD
        • Smith TWR
        • Ebner AA
        • Bolling SF.
        Combined MitraClip edge-to-edge repair with Millipede IRIS mitral annuloplasty.
        JACC Cardiovasc Interv. 2018; 11: 323-324