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Transcatheter Mitral Valve Repair
Malcolm Anastasius, MBBS, MM, PhD, FRACP; Jonathon Leipsic, MD, FRCPC, FSCCT
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KEY FACTS

  • Mitral Valve Disease

    • Indications for Transcatheter Mitral Valve Repair

      • Transcatheter Mitral Valve Repair Strategies

        • Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair

          TERMINOLOGY

          • Mitral Valve Disease

            • Mitral valve apparatus is composed of anterior and posterior leaflet, chordae tendineae, anterolateral and posteromedial papillary muscles and mitral annulus
            • Mitral regurgitation (MR) is most common disorder involving mitral valve and can be classified as either primary or secondary
              • Primary MR is intrinsic structural or degenerative abnormality of valve [e.g., mitral valve prolapse (MVP)]
              • Secondary MR is result of disease process of left ventricle that affects mechanics and function of mitral valve apparatus (e.g., ischemic or nonischemic dilated cardiomyopathy)
            • Rheumatic fever is most common cause of mitral stenosis (MS)
            • Degenerative calcific mitral valve disease is largely seen in elderly population
            • MS can result from leaflet thickening, commissural fusion, and chordal shortening and fusion
          • Indications for Transcatheter Mitral Valve Repair

            • Patients deemed high surgical risk following assessment by heart team with one of the following
              • Primary mitral valve regurgitation: Severe symptomatic mitral regurgitation
              • Asymptomatic: Left ventricular systolic ejection fraction (LVEF) < 60%, left ventricular end-systolic diameter (LVESD) > 45 mm, atrial fibrillation (AF), systolic pulmonary pressure > 50 mm Hg
              • Secondary functional MR: Severe MR despite optimal medical therapy and cardiac resynchronization therapy (CRT)
            • Indications for percutaneous balloon mitral valvuloplasty (PBMV) as therapy for MS
            • Echocardiography is primary imaging modality for establishing the severity of MR and MS
              • Severe MR is characterized by regurgitant volume of 60 mL, regurgitant fraction of 50%, and effective orifice area of > 0.4 cm²
          • Transcatheter Mitral Valve Repair Strategies

            • Percutaneous mitral valve repair for severe MR includes edge-to-edge repair (MitraClip) and annuloplasty rings (e.g., Cardioband), and PBMV for severe MS
            • MitraClip (Abbott Vascular, Menlo Park, California): Can be considered for treatment of moderate to severe and severe degenerative and functional MR
              • Device is delivered to mitral valve via femoral vein following transeptal puncture
              • Aligned above mitral valve and centered over origin of regurgitant jet, advanced across valve orifice, followed by grasping and coapting of leaflets
              • EVERST II trial evaluated MitraClip for treatment of degenerative and functional MR, and at 5 years conventional surgery resulted in greater freedom from death, surgery, or moderate/moderate-severe MR compared to MitraClip device
              • In recently completed COAPT trial of patients with only symptomatic secondary functional MR, device resulted in significant reduction in heart failure hospitalization and all cause mortality at 2 years compared to medical therapy
              • General exclusion criteria: LVEF < 25%, LVESD > 70 mm, mitral valve orifice area < 4 cm²
            • Cardioband system (Valtech Cardio, OrYehuda Israel): Traditionally, annuloplasty has been combined with mitral valve repair for degenerative MR to improve leaflet coaptation and long-term durability of repair
              • Percutaneous annuloplasty can be performed in isolation using Cardioband device in setting of functional MR resulting from left ventricular systolic dysfunction, mitral annular dilatation, and lateral papillary muscle displacement
              • Surgical-like annuloplasty device that is implanted along posterior mitral annulus
              • Delivered to left arium following femoral vein access and transeptal puncture
              • After implantation, device is contracted to remodel annulus and reduce MR
              • Early evidence for this device in symptomatic patients with secondary functional MR despite optimal medical therapy, has shown feasibility and safety in small sample size (n = 31) of high-risk patients with MR
              • CT may be used to assess the following in planning for Cardioband device implantation
                • Location of transeptal puncture, left circumflex coronary artery anatomy in relation to mitral annulus (to minimize risk of injury)
              • Exclusion criteria: Patients with LVEF < 25% and end-diastolic diameter ≥ 70 mm, primary (organic) lesions of mitral valve and calcification of mitral annulus
            • Percutaneous balloon mitral valvuloplasty (PBMV): Inoue balloon (Toray industries, Japan) is delivered to mitral valve via femoral vein following transeptal puncture
              • Balloon catheter is advanced into left ventricle, pulled back with distal portion of balloon inflated; proximal portion and waist are then inflated
              • Main mechanism of PBMV action is commissural fracture, leading to reduction in transmitral pressure gradient, increasing MV area and cardiac output
              • Superior to surgical commissurotomy, with lager resulting valve area and better durability
              • 1st-line therapy in absence of contraindications
              • Inclusion criteria: Severe symptomatic MS (mitral valve area < 1.5 cm²)
              • Asymptomatic patients: Resting systolic pulmonary arterial pressure > 50 mm Hg, new-onset AF, history of embolism
              • Echocardiography is used to determine suitability for PBMV, depending on leaflet mobility, thickening, calcification, and subvalvular thickening (Wilkins score)
              • Contraindications: Mitral valve area >1.5 cm², left atrial thrombus, > mild MR, severe bicommissural calcification, severe CAD requiring bypass

          IMAGING ANATOMY

          • Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair

            Selected References

            1. Stone GW et al: Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. ePub, 2018
            2. Baumgartner H et al: 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 38(36):2739-91, 2017
            3. Maisano F et al: Cardioband, a transcatheter surgical-like direct mitral valve annuloplasty system: early results of the feasibility trial. Eur Heart J. 37(10):817-25, 2016
            4. Nishimura RA et al: Mitral valve disease--current management and future challenges. Lancet. 387(10025):1324-34, 2016
            5. Feldman T et al: Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol. 66(25):2844-54, 2015
            6. Feldman T et al: Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 63(20):2057-68, 2014
            7. Bolen MA et al: Prospective ECG-triggered, axial 4-D imaging of the aortic root, valvular, and left ventricular structures: a lower radiation dose option for preprocedural TAVR imaging. J Cardiovasc Comput Tomogr. 6(6):393-8, 2012
            8. Ewe SH et al: Role of computed tomography imaging for transcatheter valvular repair/insertion. Int J Cardiovasc Imaging. 27(8):1179-93, 2011
            9. Feuchtner GM et al: Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography1. Radiology. 254(2):374-83, 2010
            10. Alkadhi H et al: Mitral annular shape, size, and motion in normals and in patients with cardiomyopathy: evaluation with computed tomography. Invest Radiol. 44(4):218-25, 2009
            11. Delgado V et al: Assessment of mitral valve anatomy and geometry with multislice computed tomography. JACC Cardiovasc Imaging. 2(5):556-65, 2009
            12. Feldman T et al: Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol. 54(8):686-94, 2009
            13. Guo YK et al: Isolated mitral regurgitation: quantitative assessment with 64-section multidetector CT--comparison with MR imaging and echocardiography. Radiology. 252(2):369-76, 2009
            14. Nobuyoshi M et al: Percutaneous balloon mitral valvuloplasty: a review. Circulation. 119(8):e211-9, 2009
            Related Anatomy
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            Related Differential Diagnoses
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            References
            Tables

            Tables

            KEY FACTS

            • Mitral Valve Disease

              • Indications for Transcatheter Mitral Valve Repair

                • Transcatheter Mitral Valve Repair Strategies

                  • Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair

                    TERMINOLOGY

                    • Mitral Valve Disease

                      • Mitral valve apparatus is composed of anterior and posterior leaflet, chordae tendineae, anterolateral and posteromedial papillary muscles and mitral annulus
                      • Mitral regurgitation (MR) is most common disorder involving mitral valve and can be classified as either primary or secondary
                        • Primary MR is intrinsic structural or degenerative abnormality of valve [e.g., mitral valve prolapse (MVP)]
                        • Secondary MR is result of disease process of left ventricle that affects mechanics and function of mitral valve apparatus (e.g., ischemic or nonischemic dilated cardiomyopathy)
                      • Rheumatic fever is most common cause of mitral stenosis (MS)
                      • Degenerative calcific mitral valve disease is largely seen in elderly population
                      • MS can result from leaflet thickening, commissural fusion, and chordal shortening and fusion
                    • Indications for Transcatheter Mitral Valve Repair

                      • Patients deemed high surgical risk following assessment by heart team with one of the following
                        • Primary mitral valve regurgitation: Severe symptomatic mitral regurgitation
                        • Asymptomatic: Left ventricular systolic ejection fraction (LVEF) < 60%, left ventricular end-systolic diameter (LVESD) > 45 mm, atrial fibrillation (AF), systolic pulmonary pressure > 50 mm Hg
                        • Secondary functional MR: Severe MR despite optimal medical therapy and cardiac resynchronization therapy (CRT)
                      • Indications for percutaneous balloon mitral valvuloplasty (PBMV) as therapy for MS
                      • Echocardiography is primary imaging modality for establishing the severity of MR and MS
                        • Severe MR is characterized by regurgitant volume of 60 mL, regurgitant fraction of 50%, and effective orifice area of > 0.4 cm²
                    • Transcatheter Mitral Valve Repair Strategies

                      • Percutaneous mitral valve repair for severe MR includes edge-to-edge repair (MitraClip) and annuloplasty rings (e.g., Cardioband), and PBMV for severe MS
                      • MitraClip (Abbott Vascular, Menlo Park, California): Can be considered for treatment of moderate to severe and severe degenerative and functional MR
                        • Device is delivered to mitral valve via femoral vein following transeptal puncture
                        • Aligned above mitral valve and centered over origin of regurgitant jet, advanced across valve orifice, followed by grasping and coapting of leaflets
                        • EVERST II trial evaluated MitraClip for treatment of degenerative and functional MR, and at 5 years conventional surgery resulted in greater freedom from death, surgery, or moderate/moderate-severe MR compared to MitraClip device
                        • In recently completed COAPT trial of patients with only symptomatic secondary functional MR, device resulted in significant reduction in heart failure hospitalization and all cause mortality at 2 years compared to medical therapy
                        • General exclusion criteria: LVEF < 25%, LVESD > 70 mm, mitral valve orifice area < 4 cm²
                      • Cardioband system (Valtech Cardio, OrYehuda Israel): Traditionally, annuloplasty has been combined with mitral valve repair for degenerative MR to improve leaflet coaptation and long-term durability of repair
                        • Percutaneous annuloplasty can be performed in isolation using Cardioband device in setting of functional MR resulting from left ventricular systolic dysfunction, mitral annular dilatation, and lateral papillary muscle displacement
                        • Surgical-like annuloplasty device that is implanted along posterior mitral annulus
                        • Delivered to left arium following femoral vein access and transeptal puncture
                        • After implantation, device is contracted to remodel annulus and reduce MR
                        • Early evidence for this device in symptomatic patients with secondary functional MR despite optimal medical therapy, has shown feasibility and safety in small sample size (n = 31) of high-risk patients with MR
                        • CT may be used to assess the following in planning for Cardioband device implantation
                          • Location of transeptal puncture, left circumflex coronary artery anatomy in relation to mitral annulus (to minimize risk of injury)
                        • Exclusion criteria: Patients with LVEF < 25% and end-diastolic diameter ≥ 70 mm, primary (organic) lesions of mitral valve and calcification of mitral annulus
                      • Percutaneous balloon mitral valvuloplasty (PBMV): Inoue balloon (Toray industries, Japan) is delivered to mitral valve via femoral vein following transeptal puncture
                        • Balloon catheter is advanced into left ventricle, pulled back with distal portion of balloon inflated; proximal portion and waist are then inflated
                        • Main mechanism of PBMV action is commissural fracture, leading to reduction in transmitral pressure gradient, increasing MV area and cardiac output
                        • Superior to surgical commissurotomy, with lager resulting valve area and better durability
                        • 1st-line therapy in absence of contraindications
                        • Inclusion criteria: Severe symptomatic MS (mitral valve area < 1.5 cm²)
                        • Asymptomatic patients: Resting systolic pulmonary arterial pressure > 50 mm Hg, new-onset AF, history of embolism
                        • Echocardiography is used to determine suitability for PBMV, depending on leaflet mobility, thickening, calcification, and subvalvular thickening (Wilkins score)
                        • Contraindications: Mitral valve area >1.5 cm², left atrial thrombus, > mild MR, severe bicommissural calcification, severe CAD requiring bypass

                    IMAGING ANATOMY

                    • Role of CT in Assessment of MR/MS and Planning for Transcatheter Mitral Repair

                      Selected References

                      1. Stone GW et al: Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. ePub, 2018
                      2. Baumgartner H et al: 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 38(36):2739-91, 2017
                      3. Maisano F et al: Cardioband, a transcatheter surgical-like direct mitral valve annuloplasty system: early results of the feasibility trial. Eur Heart J. 37(10):817-25, 2016
                      4. Nishimura RA et al: Mitral valve disease--current management and future challenges. Lancet. 387(10025):1324-34, 2016
                      5. Feldman T et al: Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol. 66(25):2844-54, 2015
                      6. Feldman T et al: Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 63(20):2057-68, 2014
                      7. Bolen MA et al: Prospective ECG-triggered, axial 4-D imaging of the aortic root, valvular, and left ventricular structures: a lower radiation dose option for preprocedural TAVR imaging. J Cardiovasc Comput Tomogr. 6(6):393-8, 2012
                      8. Ewe SH et al: Role of computed tomography imaging for transcatheter valvular repair/insertion. Int J Cardiovasc Imaging. 27(8):1179-93, 2011
                      9. Feuchtner GM et al: Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography1. Radiology. 254(2):374-83, 2010
                      10. Alkadhi H et al: Mitral annular shape, size, and motion in normals and in patients with cardiomyopathy: evaluation with computed tomography. Invest Radiol. 44(4):218-25, 2009
                      11. Delgado V et al: Assessment of mitral valve anatomy and geometry with multislice computed tomography. JACC Cardiovasc Imaging. 2(5):556-65, 2009
                      12. Feldman T et al: Percutaneous mitral repair with the MitraClip system: safety and midterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol. 54(8):686-94, 2009
                      13. Guo YK et al: Isolated mitral regurgitation: quantitative assessment with 64-section multidetector CT--comparison with MR imaging and echocardiography. Radiology. 252(2):369-76, 2009
                      14. Nobuyoshi M et al: Percutaneous balloon mitral valvuloplasty: a review. Circulation. 119(8):e211-9, 2009