A Clip in time – Selecting Interventions for Severe Mitral Valve Regurgitation

Abstract

Therapeutic options for the management of severe, symptomatic mitral valve regurgitation (MR) have expanded considerably over the past two decades. This is attributable to an increase in understanding of the complex anatomy and physiology of the valve apparatus [ 1 Jensen M.O. Hagege A.A. Otsuji Y. Levine R.A. Network L.T.M. The unsaddled annulus: biomechanical culprit in mitral valve prolapse?. Circulation. 2013; 127: 766-768 Crossref PubMed Scopus (21) Google Scholar , 2 Lee A.P. Hsiung M.C. Salgo I.S. Fang F. Xie J.M. Zhang Y.C. et al. Quantitative analysis of mitral valve morphology in mitral valve prolapse with real-time 3-dimensional echocardiography: importance of annular saddle shape in the pathogenesis of mitral regurgitation. Circulation. 2013; 127: 832-841 Crossref PubMed Scopus (131) Google Scholar ], to better imaging of the valve [ 3 Ennis D.B. Rudd-Barnard G.R. Li B. Fonseca C.G. Young A.A. Cowan B.R. et al. Changes in mitral annular geometry and dynamics with beta-blockade in patients with degenerative mitral valve disease. Circ Cardiovasc Imaging. 2010; 3: 687-693 Crossref PubMed Scopus (17) Google Scholar , 4 Grewal J. Suri R. Mankad S. Tanaka A. Mahoney D.W. Schaff H.V. et al. Mitral annular dynamics in myxomatous valve disease: new insights with real-time 3-dimensional echocardiography. Circulation. 2010; 121: 1423-1431 Crossref PubMed Scopus (202) Google Scholar , 5 Kim K. Kaji S. An Y. Yoshitani H. Takeuchi M. Levine R.A. et al. Mechanism of asymmetric leaflet tethering in ischemic mitral regurgitation: 3D analysis with multislice CT. JACC Cardiovasc Imaging. 2012; 5: 230-232 Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar ], and to the development of novel surgical implements and strategies to manage the spectrum of pathologies that affect the valve leaflets and support structures [ [6] Glower D.D. Surgical approaches to mitral regurgitation. J Am Coll Cardiol. 2012; 60: 1315-1322 Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar ]. Whereas surgical approaches of the past were limited to valve replacement, ring annuloplasty, and quadrangular resection of the posterior valve leaflet [ [7] Carpentier A. Cardiac valve surgery - the “French correction”. J Thorac Cardiovasc Surg. 1983; 86: 323-337 PubMed Google Scholar ], contemporary surgical approaches aim to preserve leaflet mobility, increase leaflet coaptation, and limit changes to the annular geometry [ [8] Holubec T. Sundermann S.H. Jacobs S. Falk V. Chordae replacement versus leaflet resection in minimally invasive mitral valve repair. Ann Cardiothorac Surg. 2013; 2: 809-813 Google Scholar ]. These strategies, which include shortening, elongation, and relocation of the papillary muscles or chords, and chordal replacement using polytetrafluoroethylene (ePTFE) neochords [ [8] Holubec T. Sundermann S.H. Jacobs S. Falk V. Chordae replacement versus leaflet resection in minimally invasive mitral valve repair. Ann Cardiothorac Surg. 2013; 2: 809-813 Google Scholar ], now allow successful repair of anterior and bileaflet prolapse, and facilitate minimally invasive approaches via endoscopic or robot-assisted lateral mini-thoracotomy [ 9 Goldstone A.B. Alturi P. Szeto W.Y. Trubelja A. Howard J.L. MacArthur Jr., J.W. et al. Minimally invasive approach provides at least equivalent results for surgical correction of mitral regurgitation: a propensity-matched comparison. J Thorac Cardiovasc Surg. 2013; 145: 748-756 Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar , 10 Bush B. Nifong L.W. Alwair H. Chitwood W.R. Robotic mitral valve surgery - current status and future directions. Ann Cardiothorac Surg. 2013; 2: 814-817 PubMed Google Scholar ].