Anesthetic Considerations for the Transcatheter Management of Mitral Valve Disease

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights from 2019

“…Similar to the substantial advancements in TAVR over the past decade, transcatheter mitral valve therapy has also demonstrated significant progress despite the heterogeneity in etiology, mechanisms, and pathologies of mitral valve disorders. 20,21 This section provides an update on transcatheter mitral valve therapies, including repair and replacement.…”

“…[21][22][23] A classification of these technologies on the basis of anatomic targets has been proposed as follows: (1) leaflet interventions: ablation, plication, and coaptation; (2) annular interventions: direct annuloplasty, and indirect annuloplasty via the coronary sinus; and (3) chordal interventions: implantation of neochords. [21][22][23] In this family of devices, the MitraClip system (Abbott, Santa Clara, CA) reduces mitral regurgitation through precise applications of leaflet clip(s) to improve leaflet coaptation with edge-to-edge repair. 24 The conduct of this procedure has been reviewed in a stepwise fashion in the journal with a focus on intraoperative imaging guidance with transesophageal echocardiography.…”

“…30 Although this device has commercial approval in Europe, it is currently under evaluation in major clinical trials across the United States in both degenerative and functional mitral regurgitation. [20][21][22] As alternatives to the MitraClip are developed, multicenter experience with this leaflet coaptation device continues to grow in the management of highrisk patients with secondary mitral regurgitation associated with heart failure. 31,32 The findings in these trials depend not only on the transcatheter reduction of mitral regurgitation, but also level of baseline risk and the degree of aggressive medical management before and after the mitral valve procedure.…”

“…[31][32][33] In concert with the momentum in transcatheter interventions for the mitral leaflet, the progress continues with transcatheter options for mitral annuloplasty, whether direct or indirect. [21][22][23] The Cardioband system (Edwards Lifesciences, Irvine, CA) is a transcatheter direct annuloplasty device that is delivers to the posterior mitral annulus via in a transvenous and then transseptal fashion. 34 The device is positioned and tightened with 3-dimensionsal transesophageal imaging guidance.…”

“…The transcatheter mitral valve prosthesis must avoid structural damage to neighboring structures such as the coronary sinus, left ventricular outflow tract, and the circumflex artery. 21,45 Furthermore, the dedicated prosthesis must also remain stiff during the dynamic stages of the cardiac cycle and adapt to the asymmetrical saddle shaped annulus. [43][44][45] In an early single-center experience over 5 years of percutaneous mitral valve-in-valve replacement, major bleeding was the most common complication.…”