Transcatheter Valve Repair for Patients With Mitral Regurgitation: 30-Day Results of the CLASP Study

PASCAL-based mitral valve repair in an all-comer population: acute and mid-term clinical results

AIMS

We investigated short and mid-term safety and efficacy of the PASCAL system for percutaneous mitral valve repair (PMVr) in severe mitral regurgitation (MR) in an all-comer population.

METHODS AND RESULTS

In the first consecutive 41 patients undergoing PMVr using the PASCAL system in our centre, procedural success and safety were assessed. Efficacy in improving MR and functional class were evaluated. Median patient age was 74 years, 58.5% were male patients, and median European System for Cardiac Operative Risk Evaluation Score II was 5.1%. All patients suffered from severe MR with 59% functional MR, 29% degenerative MR, and 12% of mixed aetiology MR. The technical success rate was 90%, limited by four cases where PASCAL implantation was aborted due to a prohibitive mitral gradient. On average, 1.16 PASCAL devices per patient were implanted. All patients successfully implanted with a PASCAL device were discharged with MR grade ≤ 2 and 79% with MR grade ≤ 1. Mean follow-up was 8.7 ± 4.9 months. Ninety-seven per cent of patients remained at MR ≤ 2 at follow-up, which translated into a significantly improved New York Heart Association functional class as well as a significant reduction of systolic pulmonary artery pressure and brain natriuretic peptide levels. The procedure-related rate for major adverse events was 3%. Neither early nor late single-leaflet detachment was found. In one patient, air embolism occurred, resulting in modification of the PASCAL instructions for use.

CONCLUSIONS

Percutaneous mitral valve repair using PASCAL in a real-world, all-comer population was feasible and safe, resulting in a significant mid-term reduction of MR with persistent clinical improvement.

Comparative computational analysis of PASCAL and MitraClip implantation in a patient-specific functional mitral regurgitation model

Transcatheter mitral leaflet approximation with MitraClip has proven to be a viable treatment option for heart failure patients with functional mitral regurgitation (MR). PASCAL is a similar clip device, but it has design features that differentiate it from MitraClip. The effects of the different clip designs are largely unknown. In this study, using a patient-specific, mitral valve-left ventricle heart model, we performed finite-element (FE) simulations to provide a head-to-head comparison of the post-operative effects that PASCAL and MitraClip have on mitral valve (MV) geometry and biomechanics in a functional MR patient. The two devices were modeled as approximations of the real devices, and three implantation configurations were simulated for each device. The results showed that for this patient case, PASCAL caused less MV deformation than MitraClip. Additionally, PASCAL implantation reduced the stresses and strains in the MV leaflets compared to pre-repair conditions, while MitraClip implantation caused them to increase. Although complete coaptation was not achieved, both devices improved leaflet coaptation and were viable MR treatment options. The FE simulations in this study can be used to quantify biomechanics involved in clip treatments and improve our understanding of complex interactions between human hosts and percutaneous clip devices.

Current devices and interventions in mitral regurgitation

Mitral regurgitation (MR) is the most common valvular disease. With a rising incidence in older age, the prevalence of relevant comorbidities inevitably increases. Considering the constantly aging population with high surgical risk, transcatheter therapy of MR is gaining increasing importance. Interventional therapy of either primary or secondary MR represents an alternative to pure drug or surgical therapy. With mitral valve transcatheter edge-to-edge repair, a well-established treatment has evolved in the past two decades. In addition, direct or indirect annuloplasty and ultimately transcatheter mitral valve implantation further expand the armamentarium. The current broad spectrum of interventional therapy options allows for patient-oriented therapy individually targeting different MR pathologies. This review discusses the current landscape of transcatheter therapies for relevant MR.

German Multicenter Experience With a New Leaflet-Based Transcatheter Mitral Valve Repair System for Mitral Regurgitation

OBJECTIVES

The aim of this study was to investigate the procedural and short-term safety and efficacy of a new leaflet-based transcatheter mitral valve repair system.

BACKGROUND

The PASCAL repair system has been recently approved for percutaneous treatment of mitral regurgitation (MR). Novel characteristics are broad paddles positioned around a central spacer and the ability for independent leaflet capture.

METHODS

Procedural and 30-day outcomes were investigated in the first 309 patients with symptomatic MR 3+/4+ treated with the PASCAL repair system at 10 sites. Primary efficacy endpoints were technical success and degree of residual MR at discharge. The primary safety endpoint was the rate of major adverse events (MAE).

RESULTS

Among the 309 patients (mean age 77 ± 10 years, 42% women, mean European System for Cardiac Operative Risk Evaluation II score 5.8 ± 4.5%) included in this study, MR etiology was degenerative in 33%, functional in 52%, and mixed in 16%. Eighty-six percent of patients were in New York Heart Association functional class III or IV. The technical success rate was 96%. Of 308 patients discharged alive, MR was ≤2+ in 93.5%. At 30 days, the MAE rate was 4.1%, with an estimated all-cause mortality rate of 2.0%, and 72% of patients were in New York Heart Association functional class ≤II (p < 0.001). Rates of device success and CLASP (Edwards PASCAL Transcatheter Mitral Valve Repair System Study) trial-defined clinical success were 81.9% and 86.9%, respectively. Single-leaflet device attachment occurred in 7 patients (2.3%).

CONCLUSIONS

Mitral valve repair with the PASCAL system in the early post-approval phase was effective and safe, with high procedural success rates and low rates of MAE. MR was significantly reduced, accompanied by significant improvement in functional status.

Feasibility Study of the Transcatheter Valve Repair System for Severe Tricuspid Regurgitation

BACKGROUND

Tricuspid regurgitation (TR) is a prevalent disease with limited treatment options.

OBJECTIVES

This is the first 30-day report of the U.S. single-arm, multicenter, prospective CLASP TR early feasibility study of the PASCAL transcatheter valve repair system in the treatment of TR.

METHODS

Patients with symptomatic TR despite optimal medical therapy, reviewed by the local heart team and central screening committee, were eligible for the study. Data were collected at baseline, discharge, and the 30-day follow-up and were reviewed by an independent clinical events committee and echocardiographic core laboratory. Feasibility endpoints included safety (composite major adverse event [MAE] rate), echocardiographic, clinical, and functional endpoints.

RESULTS

Of the 34 patients enrolled in the study, the mean age was 76 years, 53% were women, the mean Society of Thoracic Surgeons score was 7.3%, 88% had atrial fibrillation/flutter, 97% had severe or greater TR, and 79% had New York Heart Association (NYHA) functional class III/IV symptoms. Twenty-nine patients (85%) received implants; at 30 days, 85% of them achieved a TR severity reduction of at least 1 grade, with 52% with moderate or less TR (p < 0.001). The MAE rate was 5.9%, and none of the patients experienced cardiovascular mortality, stroke, myocardial infarction, renal complication, or reintervention. Eighty-nine percent of the patients improved to NYHA functional class I/II (p < 0.001), the mean 6-min walk distance improved by 71 m (p < 0.001), and the mean Kansas City Cardiomyopathy Questionnaire score improved by 15 points (p < 0.001).

CONCLUSIONS

In this early experience, the repair system performed as intended, with substantial TR reduction, favorable safety results with a low MAE rate, no mortality or reintervention, and significant improvements in functional status, exercise capacity, and quality of life. (Edwards CLASP TR EFS [CLASP TR EFS]; NCT03745313).

1-Year Outcomes for Transcatheter Repair in Patients With Mitral Regurgitation From the CLASP Study

OBJECTIVES

The authors report the CLASP (Edwards PASCAL Transcatheter Mitral Valve Repair System Study) expanded experience, 1-year outcomes, and analysis by functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR).

BACKGROUND

The 30-day results from the CLASP study of the PASCAL transcatheter valve repair system for clinically significant mitral regurgitation (MR) have been previously reported.

METHODS

Eligible patients had symptomatic MR ≥3+, were receiving optimal medical therapy, and were deemed candidates for transcatheter mitral repair by the local heart team. Primary endpoints included procedural success, clinical success, and major adverse event rate at 30 days. Follow-up was continued to 1 year.

RESULTS

One hundred nine patients were treated (67% FMR, 33% DMR); the mean age was 75.5 years, and 57% were in New York Heart Association functional class III or IV. At 30 days, there was 1 cardiovascular death (0.9%), MR ≤1+ was achieved in 80% of patients (77% FMR, 86% DMR) and MR ≤2+ in 96% (96% FMR, 97% DMR), 88% of patients were in New York Heart Association functional class I or II, 6-min walk distance had improved by 28 m, and Kansas City Cardiomyopathy Questionnaire score had improved by 16 points (p < 0.001 for all). At 1 year, Kaplan-Meier survival was 92% (89% FMR 96% DMR) with 88% freedom from heart failure hospitalization (80% FMR, 100% DMR), MR was ≤1+ in 82% of patients (79% FMR, 86% DMR) and ≤2+ in 100% of patients, 88% of patients were in New York Heart Association functional class I or II, and Kansas City Cardiomyopathy Questionnaire score had improved by 14 points (p < 0.001 for all).

CONCLUSIONS

The PASCAL transcatheter valve repair system demonstrated a low complication rate and high survival, with robust sustained MR reduction accompanied by significant improvements in functional status and quality of life at 1 year. (The CLASP Study Edwards PASCAL Transcatheter Mitral Valve Repair System Study [CLASP]; NCT03170349).

Transcatheter Repair and Replacement Technologies for Mitral Regurgitation: a European Perspective

Purpose of Review

We aimed to picture the contemporary landscape of available catheter-based repair and replacement solutions for mitral regurgitation (MR) in Europe.

Recent Findings

Edge-to-edge repair remains the dominant technique for transcatheter mitral valve repair especially in the context of secondary mitral regurgitation. Two recent randomized trials reported seemingly contradicting clinical results with transcatheter edge-to-edge repair for patients with heart failure and severe secondary MR. A proportionality framework related to secondary MR was proposed to help explain inconsistencies but requires further research. (In)Direct annuloplasty primarily aims to correct secondary MR; however, the scientific basis seems less robust. One dedicated transcatheter heart valve has the CE mark for mitral valve replacement but requires transapical access. Balloon-expandable transcatheter aortic valve platforms are emerging for transvenous transseptal mitral replacement in the context of mitral annular calcification, a failing surgical mitral bioprosthesis, or annuloplasty. Advanced computed tomography imaging techniques improved pre-procedural planning and introduced the option for modeling and simulation.

Summary

Development of a toolbox of catheter-based technologies, complementary imaging modalities, and refined patient selection offer novel perspectives to high-risk patients with primary or secondary MR. Clinical trials are required to help formulate evidence-based guidelines for the management of mitral valve disease.

Operator and Institutional Requirements for Transcatheter Mitral Valve Therapies in Australia: a CSANZ and ANZSCTS Position Statement

The expert Position Statement is a description of the requirements for Accreditation for transcatheter mitral valve therapy (TMVT) in Australia. The requirements include the need for a multidisciplinary Heart Team review of individual cases, mandatory reporting of outcome data to a national TMVT Registry, and accreditation of individuals and institutions by the Conjoint Accreditation Committee, the assigned accreditation authority.

Transcatheter Treatment of Valvular Heart Disease: A Review

IMPORTANCE

More than 40 million people are living with either mitral or aortic valve disease worldwide, and more than 180 000 heart valve replacement surgeries are performed each year in the US. Transcatheter valve repair has emerged as an important therapeutic option for patients who are candidates for heart valve replacement.

OBSERVATIONS

All transcatheter valve therapies involve a multidisciplinary team of interventional cardiologists, cardiothoracic surgeons, radiologists, echocardiographers, nurses, and social workers, termed the heart team, to determine the optimal approach for managing each patient. Transcatheter aortic valve implantation (TAVI) is an aortic valve replacement procedure that is performed percutaneously and is currently approved for patients with severe, symptomatic aortic stenosis in all surgical risk categories. The TAVI procedure can be performed using a balloon-expandable or self-expanding valve. In a low-risk cohort of patients (PARTNER [Placement of Aortic Transcatheter Valves] 3 trial), the rates of death from any cause, stroke, or rehospitalization were 8.5% for patients receiving TAVI and 15.1% for patients undergoing surgical aortic valve replacement. Decision-making regarding therapy choice should be based on individual anatomy (including the number of leaflets, annular size, and peripheral arterial anatomy), comorbidities (including concomitant coronary artery disease and aortopathies), and patient preference guide. A mitral transcatheter edge-to-edge repair device is approved by the US Food and Drug Administration for high-risk patients with degenerative and functional mitral regurgitation that has excellent safety and efficacy in these populations. In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial, the annualized rate of all hospitalizations for heart failure was 35.8% among patients who underwent transcatheter edge-to-edge repair and received medical therapy compared with 67.9% among patients in the medical therapy alone group. Transcatheter tricuspid valve repair and replacement trials are ongoing and show promise for the treatment of patients with tricuspid regurgitation, which previously had limited therapeutic options. Multimodality imaging, which includes transthoracic echocardiography, transesophageal echocardiography, computed tomography, and intracardiac echocardiography, is important for preprocedural planning, device selection, and optimal outcomes.

CONCLUSIONS AND RELEVANCE

Approximately 78 000 TAVI procedures and 10 000 transcatheter mitral valve repairs take place yearly in the US to treat patients with severe, symptomatic aortic stenosis and mitral regurgitation, respectively. Transcatheter valve therapies have expanded therapeutic options for patients, including for those who previously had no viable surgical options.

Devices for transcatheter mitral valve repair: current technology and a glimpse into the future

Introduction: Due to a large unmet need for the treatment of mitral regurgitation, transcatheter mitral valve repair devices have emerged in the last decade as an alternative therapeutic option. Given the complexity of this disease, several device systems for transcatheter mitral valve repair have been developed and are categorized according to its mechanism of action; each device has advantages and disadvantages for certain clinical and pathophysiologic characteristics, and in order to improve outcomes, proper patient selection among other key points are fundamental.Areas covered: The purpose of this article is to review the current state-of-the-art technologies available for transcatheter mitral valve repair, patient suitability, outcomes, and future perspectives.Expert opinion: Transcatheter therapy for mitral regurgitation improves outcomes and pushes the boundaries of biomedical technology while maintaining scientific rigor for device development. Surgical and percutaneous procedures should be viewed as complements to treat a wider spectrum of patients affected by this entity. Future directions from multidisciplinary innovation and cooperation will consolidate this therapeutic option.

2-Year Outcomes for Transcatheter Repair in Patients With Mitral Regurgitation From the CLASP Study

OBJECTIVES

This study reports 2-year outcomes from the multicenter, prospective, single-arm CLASP study with functional mitral regurgitation (FMR) and degenerative MR (DMR) analysis.

BACKGROUND

Transcatheter repair is a favorable option to treat MR. Long-term prognostic impact of the PASCAL transcatheter valve repair system in patients with clinically significant MR remains to be established.

METHODS

Patients had clinically significant MR ≥3+ as evaluated by the echocardiographic core laboratory and were deemed candidates for transcatheter repair by the heart team. Assessments were performed by clinical events committee to 1 year (site-reported thereafter) and core laboratory to 2 years.

RESULTS

A total of 124 patients (69% FMR, 31% DMR) were enrolled with a mean age of 75 years, 56% were male, 60% were New York Heart Association functional class III to IVa, and 100% had MR ≥3+. At 2 years, Kaplan-Meier estimates showed 80% survival (72% FMR, 94% DMR) and 84% freedom from heart failure (HF) hospitalization (78% FMR, 97% DMR), with 85% reduction in annualized HF hospitalization rate (81% FMR, 98% DMR). MR ≤1+ was achieved in 78% of patients (84% FMR, 71% DMR) and MR ≤2+ was achieved in 97% (95% FMR, 100% DMR) (all p < 0.001). Left ventricular end-diastolic volume decreased by 33 ml (p < 0.001); 93% of patients were in New York Heart Association functional class I to II (p < 0.001).

CONCLUSIONS

The PASCAL repair system demonstrated sustained favorable outcomes at 2 years in FMR and DMR patients. Results showed high survival and freedom from HF rehospitalization rates with a significantly reduced annualized HF hospitalization rate. Durable MR reduction was achieved with evidence of left ventricular reverse remodeling and significant improvement in functional status. The CLASP IID/IIF randomized pivotal trial is ongoing.

Early outcomes from the CLASP IID trial roll-in cohort for prohibitive risk patients with degenerative mitral regurgitation

OBJECTIVES

We report the 30-day outcomes from the roll-in cohort of the CLASP IID trial, representing the first procedures performed by each site.

BACKGROUND

The currently enrolling CLASP IID/IIF pivotal trial is a multicenter, prospective, randomized trial assessing the safety and effectiveness of the PASCAL transcatheter valve repair system in patients with clinically significant MR. The trial allows for up to three roll-in patients per site.

METHODS

Eligibility criteria were: DMR ≥3+, prohibitive surgical risk, and deemed suitable for transcatheter repair by the local heart team. Trial oversight included a central screening committee and echocardiographic core laboratory. The primary safety endpoint was a 30-day composite MAE: cardiovascular mortality, stroke, myocardial infarction (MI), new need for renal replacement therapy, severe bleeding, and non-elective mitral valve re-intervention, adjudicated by an independent clinical events committee. Thirty-day echocardiographic, functional, and quality of life outcomes were assessed.

RESULTS

A total of 45 roll-in patients with mean age of 83 years and 69% in NYHA class III/IV were treated. Successful implantation was achieved in 100%. The 30-day composite MAE rate was 8.9% including one cardiovascular death (2.2%) due to severe bleeding from a hemorrhagic stroke, one MI, and no need for re-intervention. MR≤1+ was achieved in 73% and ≤2+ in 98% of patients. 89% of patients were in NYHA class I/II (p < .001) with improvements in 6MWD (30 m; p = .054) and KCCQ (17 points; p < .001).

CONCLUSIONS

Early results representing sites with first experience with the PASCAL repair system showed favorable 30-day outcomes in patients with DMR≥3+ at prohibitive surgical risk.

Transcatheter mitral valve repair in a high-surgical risk patient with severe degenerative mitral regurgitation using the novel DragonFly™ Transcatheter Repair device-First in man implantation in China

Transcatheter repair of mitral regurgitation (MR) by edge‐to‐edge therapy has become increasingly accepted for patients with severe MR at high or prohibitive surgical risk in primary or degenerative mitral regurgitation (DMR). The technological approach has evolved from the initial transcatheter edge‐to‐edge device to improve on its acute reduction in MR and durability of results, particularly in complex primary pathology. In this study, we reported the first case of DragonFly™ Transcatheter Valve Repair device in a patient with severe DMR.

Bail-out edge-to-edge mitral repair for an acute single leaflet device attachment: a case report

Background

An acute single leaflet device attachment (SLDA) may occur during transcatheter mitral valve edge-to-edge repair (TMVr), if an inadequate grasping of the target leaflet and/or a leaflet injury are concomitant. The bail-out TMVr often fails due to the complex pathophysiology.

Case summary

We report a case of an acute SLDA after TMVr with the PASCAL Repair System for severe mitral regurgitation (MR) with mixed aetiology, i.e., a thin-appeared posterior leaflet and pseudo-prolapse of the anterior mitral leaflet due to mitral annular dilatation. An acute SLDA occurred 2 min after the deployment, with device detachment of the posterior leaflet. A bail-out TMVr with the MitraClip XTR system led to an optimal MR reduction with the PASCAL stabilized. Despite an adequate leaflet insertion of the 1st device achieved, the posterior leaflet was tear due to its fragile tissue characteristics. At discharge, echocardiography confirmed an optimal MR reduction to mild grade with both devices stabilized.

Discussion

The pathology of the mitral valve leaflet is essential to achieve successful TMVr procedure using edge-to-edge repair device. Since the mechanical stress to the target leaflet appears to vary according to the edge-to-edge repair devices, the leaflet tissue characteristics should be respected during device selection.

Transcatheter mitral valve repair: an overview of current and future devices

The field of transcatheter mitral valve repair (TMVr) for mitral regurgitation (MR) is rapidly evolving. Besides the well-established transcatheter mitral edge-to-edge repair approach, there is also growing evidence for therapeutic strategies targeting the mitral annulus and mitral valve chordae. A patient-tailored approach, careful patient selection and an experienced interventional team is crucial in order to optimise procedural and clinical outcomes. With further data from ongoing clinical trials to be expected, consensus in the Heart Team is needed to address these complexities and determine the most appropriate TMVr therapy, either single or combined, for patients with severe MR.

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

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.

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

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.

The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current randomized trials require careful interpretation. This collaborative position statement, developed by four key associations of the European Society of Cardiology-the Heart Failure Association (HFA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association of Cardiovascular Imaging (EACVI), and European Heart Rhythm Association (EHRA)-presents an updated practical approach to the evaluation and management of patients with HF and SMR based upon a Heart Team approach.

Percutaneous Mitral Valve Repair with the MitraClip System in the Current Clinical Practice

Severe mitral valve regurgitation (MR) carries a significant burden both in prognosis and quality of life of patients, as well as on healthcare systems, with high rates of hospitalization for heart failure. While mitral valve surgery constitutes the first-line treatment option for primary MR in suitable patients, surgical treatment for secondary severe MR remains controversial, with a substantial lack of evidence on a survival benefit. In recent decades, percutaneous mitral valve repair has emerged as an alternative treatment for patients deemed not suitable for surgery. Among several devices under development or evaluation, the MitraClip system is the most widespread and is supported by the strongest evidence. While the role of MitraClip in patients with chronic primary MR who are not deemed suitable for surgery is well established, with consistent data showing improvement in both prognosis and quality of life, MitraClip treatment in secondary MR is a rapidly evolving field. Two recent randomized clinical trials generated apparently controversial results but actually provided an interesting pathophysiologic frame that could help discerning patients who will benefit from the procedure versus patients who will not. In this review, we will discuss current treatment options for mitral regurgitation, focusing on percutaneous mitral valve repair with the MitraClip system.

Over 15 years: the advancement of transcatheter mitral valve repair

Patients with severe symptomatic mitral regurgitation, if left untreated, have a poor prognosis. In those patients not eligible for mitral valve (MV) surgery, percutaneous repair may improve clinical outcomes. In the past 15 years several devices have been developed to address different MV lesions. This manuscript will review the advancement of transcatheter MV repair through the years, focusing on technologies for which consistent clinical data is available.

Edge-to-edge repair: past challenge, current case selection and future advances

Severe mitral regurgitation (MR) is associated with heart failure and impaired survival with an annual mortality risk in excess of 5% per year for unoperated patients. Despite availability of surgical mitral valve interventions, as many as half of all patients with severe MR do not receive interventions. Transcatheter edge-to-edge repair with MitraClip has been a revolutionary therapy for MR, with over 100,000 treated patients worldwide. The usage has also expanded to different challenging anatomies as well as tricuspid regurgitation. Additionally, other transcatheter edge-to-edge repair devices are being studied. The evolution of these devices as well as what to expect in the future will be discussed here.

Treatment of isolated tricuspid regurgitation in 2020: an update

Tricuspid valve regurgitation is an insidious pathology that is associated with increased mortality if left untreated. Conversely, surgical correction of tricuspid regurgitation is burdened by poor outcomes, especially when right ventricular dysfunction, kidney disease, or liver disease occur. There is, therefore, increasing interest in transcatheter approaches as an alternative to surgery in patients at high or prohibitive surgical risk. The development of percutaneous devices to treat tricuspid regurgitation has several technical challenges, mainly because of the complexity of valve anatomy, thus requiring accurate patient selection. Here we review the currently available transcatheter approaches to treat severe tricuspid regurgitation.

Mitral regurgitation following PASCAL mitral valve repair system: A single arm meta-analysis

Major consequences of untreated severe mitral regurgitation (MR) includes heart failure, ventricular remodeling and pulmonary hypertension leading to significant morbidity and mortality. MitraClip is the most widely used device for treatment of severe MR. To overcome some of the shortcomings of MitraClip, novel devices like PASCAL mitral valve repair system are developed. We performed a single arm meta-analysis for patients with severe mitral regurgitation (MR) undergoing PASCAL mitral valve repair system. The results showed that 93.8% patients had reduction in MR grade, with an average operative time of 88 min and an average increase of 86.33 m in 6-min walk test.

An analysis of the cost-effectiveness of transcatheter mitral valve repair for people with secondary mitral valve regurgitation in the UK

BACKGROUND AND AIMS

A proportion of chronic heart failure (CHF) patients will experience regurgitation secondary to ventricular remodeling in CHF, known as functional mitral (MR) or tricuspid (TR) regurgitation. Its presence adversely impacts the prognosis and healthcare utilization in CHF patients. The advent of interventional devices for both atrioventricular valves modifies both aspects. We present an economic model structure suitable for comparing interventions used in MR and TR, and assess the cost-effectiveness of transcatheter mitral valve repair (TMVr) plus guideline directed medical therapy (GDMT) compared with GDMT alone in people with MR.

METHODS

An economic model with a lifetime time horizon was developed based on extrapolated survival data and using New York Heart Association classifications to describe disease severity in people with functional MR at high risk of surgical mortality or deemed inoperable. Cost and utility values (describing health-related quality-of-life) were assigned to patients dependent on their disease severity. The analysis was conducted from a UK National Health Service perspective. An incremental cost per additional quality-adjusted life year (QALY) was estimated, and sensitivity (one-way and probabilistic) and scenario analyses conducted.

RESULTS AND CONCLUSIONS

Compared with GDMT, the use of TMVr results in an additional 1.07 QALYs and an increase in costs of £32,267 per patient over a lifetime time horizon. The estimated incremental cost per QALY gained is £30,057 and would therefore be on the threshold of cost-effectiveness at £30,000 per quality adjusted life year. Thus, from a UK reimbursement perspective, in patients with severe functional MR who are at high risk of surgical mortality or deemed inoperable with conventional surgery, TMVr plus medical therapy is likely to represent a cost-effective treatment option compared with GDMT alone. The choice of device (MitraClip or PASCAL) will need to be confirmed once further clinical data are reported.

Transcatheter edge-to-edge mitral valve repair with the PASCAL system: early results from a real-world series

AIMS

This study sought to characterise the real-world performance and clinical outcomes of the PASCAL system, a leaflet approximation device for transcatheter mitral valve repair.

METHODS AND RESULTS

Fifty patients in NYHA Class II-IV despite optimal medical therapy (median age 78.0 years [IQR 74.5-81.0], 52% female, log EuroSCORE 21.6 [IQR 13.2-30.2]) were treated for severe mitral regurgitation (MR) and followed up for one month. Primary and secondary MR was present in 24% and 68% of patients, respectively, with a mixed aetiology observed in 8%. A 1-device strategy was employed in 26/50 patients (52%), a 2-device strategy in 23/50 (46%) patients, and a 3-device strategy in 1/50 (2%) patients. Technical and procedural success was achieved in 100% and 98% of patients, respectively. MR grade ≤1 was observed in 39/50 (78%) patients at discharge, and in 36/46 (78%) patients at one month, with transvalvular gradients remaining ≤5 mmHg in all patients. One device embolisation and one single leaflet device attachment were observed during follow-up. After one month, 73% of patients reported an improvement in NYHA class, and six-minute walk test distance increased by 73±12 m in patients without relevant tricuspid regurgitation.

CONCLUSIONS

In a real-world population, the PASCAL device effectively reduces MR and leads to functional improvements on short-term follow-up.

Transcatheter Mitral Valve Repair and Replacement: What's on the Horizon?

There are more than 4 million people affected by mitral regurgitation in both the United States and Europe. Prior to the last decade the only options for treatment of MR were medical therapy and open-heart surgery which left many high risk patients with little option once medically optimized. However, we saw a flood in innovative transcatheter mitral valve interventions. As the technologies are refined these new approaches are considerably less invasive and for some high-risk patients may represent a superior option to conventional open-heart surgery. There are 3 main approaches currently being considered for transcatheter mitral valve repair, edge to edge repair, indirect annuloplasty and direct annuloplasty. There have also been large advancements in recent years in transcatheter replacement of the mitral valve. Although many of these devices are under investigation still, we sought to examine the current state of innovative transcatheter mitral valve technologies.

Mid-term hemodynamic and functional results after transcatheter mitral valve leaflet repair with the new PASCAL device

AIMS

To examine the functional and hemodynamic mid-term outcome at 5 months of mitral regurgitation (MR) reduction using the PASCAL repair system.

METHODS AND RESULTS

Between July 2019 and February 2020 31 consecutive patients with MR 3 +/4 + (mean age 77.5 years, all in New York Heart Association (NYHA) class III-IV, STS score 9.1 ± 7.4) underwent MR reduction in our institute using the PASCAL device. 61.3% had a functional, 29.0% a degenerative, and 9.7% a mixed etiology. Successful implantation was achieved in 30/31 (96.8%) patients. 27/31 patients (87.1%) completed 5-month follow-up with clinical, echocardiographic, laboratory and hemodynamic assessment. At 5 months, 70.4% of the patients had MR grade ≤ 1 (p < 0.001). 85.2% were in NYHA class I or II (p < 0.001). Six-minute walk distance improved by 145 m (p = 0.010), Kansas City cardiomyopathy questionnaire and European quality of life 5 dimensions questionnaire (EQ5D) improved by 31 (p < 0.001) and 9 points (p = 0.001), respectively. Mean pulmonary capillary wedge pressure decreased significantly from 22.1 ± 9 mmHg to 17.3 ± 8 mmHg (p = 0.041) and right atrial pressure from 10.3 ± 6 mmHg to 8.0 ± 6 mmHg (p = 0.013) from baseline to 5 months. In addition, propensity score matching showed that PASCAL and MitraClip procedures resulted in equally hemodynamic and functional improvement.

CONCLUSION

MR reduction of severe MR with the PASCAL device is feasible and safe regardless of etiologies. Mid-term follow-up at 5 months showed a sustained MR reduction, improvement of exercise capacity, quality of life, proBNP levels and hemodynamics regarding pulmonary capillary wedge pressure and right atrial pressure.

Percutaneous Edge-to-Edge Mitral Valve Repair

Percutaneous edge-to-edge mitral valve repair, using the MitraClip device for severe mitral regurgitation (MR) was first introduced in 2003. Since then, more than 100,000 cases have been performed worldwide and it remains the most established percutaneous therapy available for the treatment of severe MR. Currently, it is indicated for severe, symptomatic functional MR in patients who continue to have significant symptoms despite optimal guideline directed medical therapy, as well as in symptomatic patients with severe degenerative MR who are deemed too high risk for conventional surgical therapy in the opinion of the heart team. In this paper, we discuss the evolution of the MitraClip device, the clinical studies supporting its use as well as the important concept of proportionate and disproportionate MR.

Outcomes with percutaneous mitral repair vs. optimal medical treatment for functional mitral regurgitation: systematic review

Functional mitral regurgitation (MR) could be defined as a ventricular disease where mitral valve is structurally normal, left chambers are enlarged and mitral annulus is dilated with lack of coaptation of leaflets. Transcatheter mitral valve repair technique has broadened the therapeutic range in the treatment of severe MR. The aim of this study was to review outcomes of MitraClip vs. medical treatment for functional MR. We also planned to review the concept of functional MR, assessment of the degree, prognosis and therapy options. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Medline through PubMed database was used to search. The present review included manuscripts published between January 2009 and September 2019. Two authors independently screened titles and abstracts of all publications, and performed the selection of studies and data extraction. In the case of disagreements, consensus meetings reached the final decision. Inclusion criteria were: (I) randomized controlled trials and (II) works must compare MitraClip versus optimal medical treatment. Transcatheter mitral valve repair along optimal medical treatment has been compared with optimal medical therapy in two different randomized trials. In the COAPT trial, the MitraClip group showed a significant reduction in mortality and heart failure (HF) hospitalizations. In the MITRA-FR trial, no significant differences were observed between both groups. We reviewed important aspects of functional MR and performed a comprehensive review of both trials comparing them and focusing on their differences.

Percutaneous mitral repair: current and future devices

Mitral regurgitation (MR) is the second most common valvular heart disease and its prevalence is increasing with population ageing. In the recent years we have witnessed the development of several transcatheter devices to correct MR in patients at high-risk for surgery. The majority of evidence regarding safety and efficacy of this new therapy comes from MitraClip studies. However, new alternatives on the field of valve repair have emerged with promising results. The aim of this review is to portrait the landscape of transcatheter mitral repair alternatives, from currently used devices to those that will have a role in the near future.

Mitral and Tricuspid Transcatheter Interventions Current Indications and Future Directions

Valvular heart disease is responsible for a high rate of morbidity and mortality, especially in the elderly population. With the emergence of new transcatheter treatment options, the therapeutic spectrum for patients with valvular heart disease has considerably expanded during the past years. Interventional treatment of the mitral and tricuspid valve requires an individualized and versatile approach owing to the different etiologies of valvular dysfunction and the complex anatomy of the atrioventricular valves. This article aims to review recent developments, summarize the evidence, indications and limitations of the available systems, and provide a glimpse into the future of transcatheter interventions for the treatment of mitral and tricuspid valve disease.

Imaging and Patient Selection for Transcatheter Tricuspid Valve Interventions

With the emergence of transcatheter solutions for the treatment of tricuspid regurgitation (TR) increased attention has been directed to the once neglected tricuspid valve (TV) complex. Recent studies have highlighted new aspects of valve anatomy and TR etiology. The assessment of valve morphology along with quantification of regurgitation severity and RV function pose several challenges to cardiac imagers guiding transcatheter valve procedures. This review article aims to give an overview over the role of modern imaging modalities during assessment and treatment of the TV.

New developments in transcatheter therapy of mitral valve disease

Mitral valve regurgitation (MR) belongs to one of the most common acquired valve diseases in western countries with increasing prevalence in older age. For patients with high perioperative risk and older age prohibitive for valve surgery, the development of transcatheter mitral valve therapies offers new options. Assessment of the severity and etiology of MR and thorough imaging of the mitral valve anatomy and pathology are necessary prerequisites for appropriate decision making in the field of transcatheter mitral valve therapies. Different transcatheter repair and replacement techniques are on the market, most of them mimicking surgical techniques. With some techniques (e.g., the MitraClip device), there is good clinical experience (>80,000 devices implanted worldwide), and evidence (three randomized studies), whereas for newer procedures, safety and efficacy data are still very limited. Transcatheter mitral repair and replacement techniques have to be considered as complementary treatment options for high-risk patients indicated by the Heart Teams. The different techniques and devices will be introduced and discussed in the following paper.