Percutaneous Mitral Valve Interventions (Repair): Current Indications and Future Perspectives

Abstract

Mitral valve regurgitation (MR) is the commonest valvular abnormality encountered among adult patients with cardiac valvular disease and conveys significant morbidity and mortality. The mitral valve is a complex anatomical structure and etiology for regurgitation is classified as either primary or secondary MR. Identification of the etiology in severe MR is critical in determining the appropriate treatment strategy. Transcatheter mitral valve repair (TMVR) is a minimally invasive technique for treatment of selected patients with symptomatic chronic moderate-severe or severe (3 to 4+) MR. While surgery remains the mainstay for treatment in primary MR, several technological advances within the last decade have made transcatheter mitral valve intervention increasingly feasible and safe in clinical practice. Use of TMVR in patients with severe MR has successfully reduced patient symptoms, disease morbidity, improved quality of life, and facilitated reverse remodeling with potential for a survival advantage among certain patients with secondary MR. Recent randomized controlled trials on MitraClip use in secondary MR have reinvigorated interest in this disease and refocused our attention on optimizing patient selection and timing of intervention to maximize benefit from using such percutaneous devices. In our review, we discuss etiologies and pathophysiology in both acute MR and development of chronic severe MR. We discuss management strategies for MR among patients based on etiology, particularly percutaneous mitral valve interventional therapies. We perform an extensive review comparing and contrasting existing data on safety, efficacy, durability, and appropriate patient selection related to MitraClip implantation in both primary and secondary MR. Lastly, we explore percutaneous MV therapies beyond the MitraClip as we await larger scale trials on these devices prior to them making way into day-to-day practice.

Surgery for heart failure: Treatment options and implications

“…It is based on the edge‐to‐edge technique, creating a “double orifice” MV. It has been approved for the treatment of MR in Europe in 2008, but only gained approval for FMR treatment in America in 2019, following the publication of two high profile trials: COAPT and MITRA FR 60 (Table 4). Although both studies assessed the effectiveness of MitraClip and GDMT compared to GDMT alone, the COAPT reported a 38% reduction in mortality and 47% decrease in hospitalization rates among patients treated with MitraClip in contrast to those on medical therapy after 2 years, while the MITRA FR reported no difference in the primary endpoint of all‐cause mortality or HF hospitalization between the two groups at 1 year 53,61 .…”

Initial experience with percutaneous mitral valve repair in patients with cardiac amyloidosis

“…When compared to the even more advanced amyloid disease in the control group, our data may also add to the idea of importance of the right timing for PMVR in cardiac amyloidosis, as already described for other patient cohorts. 61 Considering PMVR in cardiac amyloidosis especially at an early stage could therefore be a feasible treatment option.…”

Transcatheter Mitral Valve Repair and Replacement: Analysis of Recent Data and Outcomes

“…This requires both femoral and subclavian venous access. 1 In 2017, the first-inman results involving 5 patients were published. 47 That study involved 5 patients with severe secondary MR with a primary efficacy endpoint of change in MR severity at 1 month.…”

“…MITRAL REGURGITATION (MR) is a common valvular abnormality and is accompanied by significant morbidity and mortality. 1 Although surgery has been considered the primary procedural option to treat MR, percutaneous transcatheter interventions are gaining traction rapidly as preferred therapies. These percutaneous interventions primarily have been marketed as a minimally invasive option for patients with high surgical risk.…”

“…Newer transcatheter mitral valve interventions in patients with mitral regurgitation. Reproduced without modification with permission from Shah et al1 under the Creative Commons Attribution License CC BY (https://creativecommons.org/licenses/by/4.0/). Ó 2019 Mahek Shah and Ulrich P. Jorde.…”