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. 2023 Jan 23;18(12):957-976.
doi: 10.4244/EIJ-D-22-00725.

Mitral valve transcatheter edge-to-edge repair

Jörg Hausleiter  1 , Thomas J Stocker  1 , Marianna Adamo  2 , Nicole Karam  3 , Martin J Swaans  4 , Fabien Praz  5
Affiliations

Mitral valve transcatheter edge-to-edge repair

Jörg Hausleiter et al. EuroIntervention. .

Abstract

Mitral regurgitation (MR) is the most prevalent valvular heart disease and, when left untreated, results in reduced quality of life, heart failure, and increased mortality. Mitral valve transcatheter edge-to-edge repair (M-TEER) has matured considerably as a non-surgical treatment option since its commercial introduction in Europe in 2008. As a result of major device and interventional improvements, as well as the accumulation of experience by the interventional cardiologists, M-TEER has emerged as an important therapeutic strategy for patients with severe and symptomatic MR in the current European and American guidelines. Herein, we provide a comprehensive up-do-date overview of M-TEER. We define preprocedural patient evaluation and highlight key aspects for decision-making. We describe the currently available M-TEER systems and summarise the evidence for M-TEER in both primary mitral regurgitation (PMR) and secondary mitral regurgitation (SMR). In addition, we provide recommendations for device selection, intraprocedural imaging and guiding, M-TEER optimisation and management of recurrent MR. Finally, we provide information on major unsolved questions and "grey areas" in M-TEER.

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Conflict of interest statement

J. Hausleiter has received speaker honoraria and research support from Edwards Lifesciences outside the submitted work. T.J. Stocker has received compensation for travel expenses from Edwards Lifesciences. M. Adamo has received speaker honoraria from Abbott Vascular and Medtronic outside the submitted work. N. Karam has received consultant fees from Abbott Vascular outside the submitted work. M.J. Swaans reports personal fees from Abbott Vascular, Boston Scientific, Philips/Volcano, Edwards Lifesciences, and BioVentrix, outside the submitted work. F. Praz has received compensation for travel expenses from Abbott Vascular, Edwards Lifesciences, and Polares Medical.

Figures

Figure 1
Figure 1. Patient stratification and simplified guideline recommendation.
Therapeutic strategies for patients with (A) symptomatic severe primary mitral regurgitation (MR) or (B) symptomatic severe secondary MR. COAPT: Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation; GDMT: guideline-directed medical therapy; HTx: heart transplantation; LVAD: left ventricular assist device; M-TEER: mitral valve transcatheter edge-to-edge repair; N: no; SMVR: surgical mitral valve repair or replacement; Y: yes
Figure 2
Figure 2. Device overview.
Technical specifications of the currently available delivery devices and implants for mitral valve transcatheter edge-to-edge repair. LA: left atrial
Figure 3
Figure 3. Leaflet optimisation and staged leaflet capture techniques.
Leaflet optimisation consists of reopening of the implant arms (A) and selective actuation of the chosen gripper/clasp (B, C). For staged leaflet capture, 1 leaflet is grasped and secured (D), then the catheter is moved towards the other leaflet (E), and the second gripper/clasp is activated (F). Reprinted with permission of Edwards Lifesciences.
Figure 4
Figure 4. Complexity of valve morphology and centre experience as criteria for mitral valve transcatheter edge-to-edge repair.
A1/P1: lateral segments of anterior (A1) and posterior (P3) mitral valve leaflet; A3/P3: medial segments of anterior (A3) and posterior (P3) mitral valve leaflet; MAC: mitral annular calcification; M-TEER: mitral valve transcatheter edge-to-edge repair; MVA: mitral valve area
Figure 5
Figure 5. Simplified COAPT criteria
Simplified COAPT criteria. Simplified in- and exclusion criteria of the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation (COAPT) study. aBNP ≥300 pg/ml or NT-proBNP ≥1,500 pg/ml. bincluding MVA >4.0 cm2. csystolic pressure ≤90 mmHg, cardiogenic shock or the need for inotropic and/or mechanical supports. dACC/AHA classification. ACC: American College of Cardiology; AHA: American Heart Association; BNP: B-type NP; COPD: chronic obstructive pulmonary disease; CoR: class of recommendation; ESC: European Society of Cardiology; HF: heart failure; LoE: level of evidence; LV: left ventricular; LVEF: left ventricular ejection fraction; M-TEER: mitral valve transcatheter edge-to-edge repair; NP: natriuretic peptide; NYHA: New York Heart Association; RV: right ventricular; SMR: secondary mitral regurgitation
Figure 6
Figure 6. Criteria to be considered for device selection.
Device selection criteria include characteristics of the regurgitant jet, baseline transmitral gradient, annular and leaflet calcification, procedural strategy, mitral valve area, anatomic complexity, and leaflet tension.
Figure 7
Figure 7. Imaging techniques for visualisation of the mitral valve.
Imaging techniques include traditional 3D rendering (A), colour Doppler (B), and 3D imaging approaches such as GlassVue (C) and TrueVue (D). The mitral valve area is measured at the beginning of the procedure to refine device selection and plan the treatment strategy (E). The transseptal puncture is performed starting from a bicaval view using an X-plane to localise and adjust the position of the needle tip in the antero-posterior plane (F). Fusion imaging is useful during catheter steering towards the mitral plane (G, H). Valve crossing and grasping is usually performed on an intercommissural view using an X-plane (I). A2: middle scallop of the anterior leaflet of the mitral valve; ant: anterior; Ao: aorta; inf: inferior; LA: left atrium; lat: lateral; LV: left ventricle; LVOT: left ventricular outflow tract; med: medial; P1, P2, P3: lateral, middle, and medial scallops of the posterior leaflet of the mitral valve; post: posterior; RA: right atrium; sup: superior
Figure 8
Figure 8. Cardiologist's 3D view of the mitral valve during transcatheter edge-to-edge repair.
In the intercommisural 2D view of the mitral valve, lateral manoeuvring of the device (*, here: PASCAL Ace implant) moves the device from left to right (A). The “cardiologist's” 3D view of the mitral valve simplifies device steering since a lateral manoeuvre leads to corresponding movement of the device from left to right (B). In contrast, the traditional “surgeon's” view does not correspond to the intercommisural 2D view of the mitral valve and lateral manoeuvring of the device leads to movement from right to left (C). Therefore, the “cardiologist's” view might be the preferred 3D echo orientation during mitral valve transcatheter edge-to-edge repair. ant: anterior; lat: lateral; med: medial; post: posterior
Figure 9
Figure 9. Fluoroscopic device orientation.
The orientation of a PASCAL Ace implant (*) is shown by fluoroscopy in an anterior-posterior (AP) projection (A). After correct orientation of the device as confirmed by 3D echo (B), the X-ray gantry should be adjusted until the device arms are superimposed and “disappear” (here: right anterior oblique [RAO] 20, cranial 10 projection) to support the control of the device orientation by fluoroscopy during subsequent leaflet grasping (C). ant: anterior; lat: lateral; med: medial; post: posterior
Figure 10
Figure 10. 4D intracardiac echocardiography.
Placement of an ICE catheter in the left atrium allows for 4D intracardiac echocardiography (A) to assess MR (B), guide leaflet grasping (C, D), and support multiple clip treatment strategies (E). In case of remaining relevant interatrial shunt (F), closure of the atrial septal defect can be easily guided from the right atrium (G). ICE: intracardiac echocardiography; LA: left atrium; LV: left ventricle; MC: MitraClip; MR: mitral regurgitation; RA: right atrium
See this image and copyright information in PMC

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