Identification and Quantification of Degenerative and Functional Mitral Regurgitation for Patient Selection for Transcatheter Mitral Valve Repair

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Key points

  • Mitral regurgitation (MR) can be due to valvular degeneration, secondary to ventricular remodeling, or a combination of the 2 mechanisms.

  • Edge-to-edge leaflet repair is the only approved transcatheter mitral valve repair technique in the United States; novel approaches targeting different components of the mitral anatomy are emerging.

  • Imaging with echocardiography establishes the cause of MR, determines anatomic feasibility of transcatheter repair, and grades the severity of MR.

  • Feasibility of

Cause and pathophysiology of mitral regurgitation

MR can result from several mechanisms, which are broadly characterized into either a primary abnormality of the valvular apparatus or a secondary dysfunction due to other cardiac disease.

Transcatheter mitral valve repair

MR is more prevalent in the elderly, nearly 10% of Americans older than 75 years of age have moderate or severe MR.1 They are also often at high or prohibitive risk for mitral valve surgery due to comorbidities. Transcatheter therapies have thus emerged as an attractive alternative to surgery for these individuals, particularly as the general population ages.

General Considerations

Assessment with echocardiography is essential to patient selection for transcatheter mitral valve repair in several ways. First, the presence of MR and its underlying mechanism can be established. Second, the anatomy of the mitral valve apparatus as it relates to the feasibility of the specific repair technique can be evaluated. Finally, the severity of MR can be quantified. Candidacy for transcatheter mitral valve repair is a nuanced decision dependent on a comprehensive patient evaluation

Quantification of mitral regurgitation

In addition to establishing the mechanism of MR and assessing mitral anatomy, determining MR severity is another key component of the evaluation for transcatheter mitral repair. Mitral repair is generally indicated for severe MR (3+ or 4+). Quantification of MR can be complicated, because of its dynamicity and susceptibility to the influence of hemodynamic loading conditions. An integrative approach is recommended to most accurately grade MR severity, given the individual limitations of each of

Summary

MR either results from valvular degeneration or is secondary to myocardial dysfunction. Transcatheter mitral valve repair techniques, especially edge-to-edge leaflet repair, are emerging as feasible therapies for patients with severe MR who are at high risk for surgery. Patient selection is a complex decision requiring a multidisciplinary heart team and depends on clinical factors, anatomic feasibility of repair, and the severity of MR. Echocardiography is the primary diagnostic tool for

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      It is also an important test to recognize factors that may predict unfavorable clinical benefits, even if the procedural outcome was optimal, such as the presence of severe tricuspid regurgitation or RV systolic dysfunction. Pre-procedural 2D and 3D TEE are critical to further define the anatomy with an emphasis on finding anatomic characteristics, which may either preclude or complicate the procedure (12, 32–34). In some cases, pre-procedural TEE is used to quantify the MR in place of an inadequate TTE (34,35).

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      The key message from our review is that hybrid techniques should prove to be the best option for complex anatomies. The safety and efficacy of the edge-to-edge repair technique with or without concomitant mitral annuloplasty, fully mimicking the surgical repair technique (for example combinations of MitraClip and CardioBand or Cardioband and NeoChord) 12 has to be confirmed by further clinical studies, while the technological improvement of available devices is expected to offer more available options.2,6 Our opinion is that this strategy could be significantly valuable in the near future, with extended indications of transcatheter techniques to younger patients at lower surgical risk, who will require perfect results and long-term durability.

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      It is estimated to affect up to 1% of adults in the United States.43 The contemporary description of mitral regurgitation has been characterized as the following 2 main types: primary, or degenerative, in which there is structural pathology of the mitral valve complex, and secondary, or functional, in which the structurally normal mitral valve leaflets are separated in systole owing to a dilated annulus and/or left ventricular dilation with consequent tethering.42–44 Percutaneous mitral valve edge-to-edge repair has been advocated as a management alternative in both major types of mitral regurgitation.35

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    Disclosure Statement: F.E. Silvestry is a site sub-investigator for Edwards CardiaQ and CardioBand. No disclosures for the remaining authors.

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