Treatment of Secondary Mitral Regurgitation in Chronic Heart Failure

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.

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.

Transcatheter reshaping of the mitral annulus in patients with functional mitral regurgitation: one-year outcomes of the MAVERIC trial

AIMS

The aim of this study was to assess the one-year safety and efficacy of the transcatheter ARTO system in the treatment of functional mitral regurgitation (FMR).

METHODS AND RESULTS

MAVERIC is a multicentre, prospective, non-randomised pre-commercial study. Eligible patients were on guideline-recommended therapy for NYHA Class II-IV systolic heart failure and had an FMR grade ≥2+. The ARTO system was implanted in forty-five (100%) patients. The primary safety composite endpoint (death, stroke, myocardial infarction, device-related surgery, cardiac tamponade, renal failure) at 30 days and one year was 4.4% (95% CI: 1.5-16.6) and 17.8% (95% CI: 9.3-32.4), respectively. Periprocedural complications occurred in seven patients (15.5% [95% CI: 6.5-29.5]), and five patients (11.1% [95% CI: 4.9-24.0]) died during one-year follow-up. Paired results for 36 patients demonstrated that 24 (66.7%) had grade 3+/4+ mitral regurgitation at baseline; however, only five (13.9%) and three (8.3%) patients remained at grade 3+/4+ 30 days and one year post procedure (p<0.0001). Echocardiographic parameters such as anteroposterior annulus diameter decreased from 41.4 mm (baseline) to 36.0 and 35.3 mm at 30 days and one year, respectively (p<0.0001). Twenty-five patients (69.4%) had baseline NYHA Class III/IV symptoms decreasing significantly to nine (25.0%) at 30 days and eight (22.2%) at one year post procedure (p<0.0001).

CONCLUSIONS

The ARTO transcatheter mitral valve repair system is both safe and effective in decreasing FMR up to one year post procedure.

Transseptal direct complete annuloplasty: early experience

Annuloplasty is a fundamental component of surgical mitral valve repair, and is employed in nearly 100% of repair operations for both primary and secondary mitral regurgitation (SMR). Developing transcatheter techniques to replicate surgical annuloplasty has been the focus of significant innovation and development in recent years. Since many patients are not offered surgery due to high perceived surgical risk, transcatheter approaches will provide new treatment options. In this manuscript, we review technologies which allow transseptal and transcatheter mitral valve (MV) annuloplasty.

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.

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.

Indirect Annuloplasty to Treat Functional Mitral Regurgitation: Current Results and Future Perspectives

The incidence of mitral regurgitation (MR) is approximately 1.7% in the developed world, and this increases to more than 10% in patients aged over 75 years. Functional (or secondary) mitral regurgitation (FMR) is defined as poor leaflet coaptation and tethering secondary to either ischemic or non-ischemic left ventricular (LV) dysfunction and dilatation. FMR is more common than degenerative (or primary) MR and is associated with significantly worse outcomes in patients with heart failure, post myocardial infarction and following coronary artery bypass graft surgery. Patients with severe degenerative MR have excellent outcomes with surgical repair, however the benefits of surgery in FMR are less clear. Although annuloplasty is associated with a lower operative mortality compared to replacement, the recurrence rate of mitral regurgitation is high in patients with FMR and neither surgical repair or replacement have been shown to reduce hospitalisation or death in FMR. Furthermore, nearly half of patients are deemed too high risk for surgery and therefore most patients are managed conservatively and there remains an unmet clinical need. Transcatheter mitral valve interventions are an emerging alternative for those at high surgical risk. This mini review focuses on indirect mitral annuloplasty: anatomical considerations, patient selection, current devices, implantation techniques and the associated clinical outcome data.