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

Abstract

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.

Keywords: endovascular procedures; heart valve prosthesis implantation; mitral valve insufficiency.

Figure 1

Carillon Mitral Contour System. (A) Components of the Carillon implanted device—the distal and proximal anchor are implanted in the great cardiac vein (GCV) and coronary sinus (CS), respectively. (B) Components of the Carillon Handle Assembly. (C and D) The implant is designed to be deployed, tensioned and secured in the coronary vein; the reduction of the mitral regurgitation is immediate and can be modulated during the procedure. Images courtesy of and provided by Cardiac Dimensions.

Figure 2

ARTO system. (A) Insertion of a guide wire in the great cardiac vein (GCV) via the right jugular vein and transseptal insertion of a guide wire and 12 Fr sheath into the left atrium (LA). (B) Insertion of GCV and LA magnetic catheters, which should connect at the side of the posterior mitral leaflet. (C) Insertion of the crossing wire from GCV to LA side through the magnetic catheters. (D) Following removal of the magnetic catheters and exchanging the crossing wire with the bridge-extension wire, implantation of the T-bar device in the lateral wall via the GCV. (E) Next, implantation of the septal device. (F) Tensioning of the ‘bridge wire’ between the T-bar in the GCV and septal anchor, resulting in shortening of the mitral annulus anterior–posterior diameter and mitral regurgitation reduction. Images courtesy of and provided by MVRx.

Figure 3

Cardioband Mitral System. (A) The Cardioband delivery system. (B) Correct positioning of the first anchor at the anterior and lateral side of the mitral annulus. (C) The anchors are repeatedly placed at the mitral annulus—covered by the polyester sleeve—until the implant catheter tip reaches the last anchoring site at the medial side. (D and E) Cinching of the Cardioband device, resulting in a reduction of the mitral annular diameter and mitral regurgitation severity. Images courtesy of and provided by Edwards Lifesciences.

Figure 4

Millipede Transcatheter Mitral Annuloplasty System. (A and B) The Millipede device has a complete semi-rigid ring design and consists of a nitinol zig-zag stent frame that is circumferentially fixed to the annulus by eight helical anchors. (C and D) The top of the frame has eight sliders that can be individually cinched to achieve patient-tailored downsizing of the mitral annulus. Images courtesy of and provided by Boston Scientific.

Figure 5

MitraClip G4 System. (A) All components of the new-generation MitraClip G4 System. (B) Two independent gripper levers allow for independent grasping of the mitral leaflets. (C) The MitraClip G4 includes four clip sizes (NT, XT, NTW and XTW) offering more options for patient-tailored mitral valve repair. (D) After steering the clip above the mitral valve and opening the clip arms, the clip is passed across the mitral leaflets into the left ventricle, the clip is gently pulled back and the leaflets are grasped by the grippers. (E) Next, the clip is closed and a double orifice mitral valve opening can be seen by 3D-TEE surgeon’s view. (F) Final result after MitraClip implantation with approximation of the anterior and posterior mitral leaflets and reduction of the mitral regurgitation. Images courtesy of and provided by Abbott.

Figure 6

PASCAL Transcatheter Valve Repair System. (A) The three components of the PASCAL delivery system. (B) The PASCAL implant consists of two paddles, two clasps and a central spacer. (C) Independent leaflet capture should enable operators to adjust leaflet insertion and capture leaflets in difficult pathologies. (D) The newest generation PASCAL Ace implant has 6 mm wide paddles and a smaller spacer that fills the regurgitant orifice and reduces the leaflet approximation distance. (E) Elongation of the PASCAL device facilitates retraction of the device from the left ventricle, if needed, with a reduced risk of getting entangled in the chords. Images courtesy of and provided by Edwards Lifesciences.

Figure 7

NeoChord Transcatheter Mitral Valve Repair. (A) Components of the NeoChord system. (B) NeoChord is a transapical, beating heart, off-pump mitral valve repair system. (C) The jaws of the device are opened and the leaflet edge is grasped by withdrawing the device from the left atrium. (D and E) A loop of the suture and a girth hitch knot can be formed through the mitral leaflet. (F and G) The length of each neo-chordae can be adjusted to achieve maximal mitral regurgitation reduction under normal left ventricular (LV) filling conditions as assessed by transesophageal echocardiography. (H) Each of the neo-chordae is tied to the LV epicardial pledget. Images courtesy of and provided by NeoChord.

Figure 8

HARPOON Mitral Valve Repair System. (A) The procedure is performed through a left lateral thoracotomy incision overlying the left ventricular (LV) apex. (B) Components of the HARPOON System: introducer and delivery system. HARPOON is a transapical, beating heart, off-pump mitral valve repair system. (C–E) Deployment of a double-helical knot through the free-edge of the leaflet and e-polytetrafluoroethylene chordal tensioning until the desired level of leaflet coaptation is obtained. Images courtesy of and provided by Edwards Lifesciences.