Abstract
Percutaneous edge-to-edge mitral valve (MV) repair using MitraClip has been recently established as a treatment option for patients with heart failure and functional mitral regurgitation (MR), which significantly expands the number of patients that can be treated with this device. This study aimed to quantify the morphologic, hemodynamic and structural changes, and evaluate the biomechanical interaction between the MitraClip and the left heart (LH) complex of a heart failure patient with functional MR using a fluid-structure interaction (FSI) modeling framework. MitraClip implantation using lateral, central and double clip positions, as well as combined annuloplasty procedures were simulated in a patient-specific LH model that integrates detailed anatomic structures, incorporates age- and gender-matched non-linear elastic material properties, and accounts for mitral chordae tethering. Our results showed that antero-posterior distance, mitral annulus spherecity index, anatomic regurgitant orifice area, and anatomic opening orifice area decreased by up to 28, 39, 52, and 71%, respectively, when compared to the pre-clip model. MitraClip implantation immediately decreased the MR severity and improved the hemodynamic profile, but imposed a non-physiologic configuration and loading on the mitral apparatus, with anterior and posterior leaflet stress significantly increasing up to 210 and 145% during diastole, respectively. For this patient case, while implanting a combined central clip and ring resulted in the highest reduction in the regurgitant volume (46%), this configuration also led to mitral stenosis. Patient-specific computer simulations as used here can be a powerful tool to examine the complex device-host biomechanical interaction, and may be useful to guide device positioning for potential favorable clinical outcomes.
Highlights
The mitral valve (MV) repair technique using MitraClip (Abbott, Santa Clara, CA, United States) is the most common percutaneous treatment option for patients with symptomatic mitral regurgitation (MR) at high surgical risk (Mauri et al, 2013)
The mitral annulus (MA) area and aortic-mitral distance had a tendency to decrease for all clip models, but these changes were only important for the double + ring model when compared to the pre-clip state
Using a lateral clip led to the smallest changes in MV geometry, while using a double clip + ring led to the biggest anatomic changes
Summary
The mitral valve (MV) repair technique using MitraClip (Abbott, Santa Clara, CA, United States) is the most common percutaneous treatment option for patients with symptomatic mitral regurgitation (MR) at high surgical risk (Mauri et al, 2013). While the COAPT trial showed that MitraClip was associated with a lower rate of hospitalization for heart failure and lower all-cause mortality within 24 months of follow-up, compared with using medical therapy alone (Stone et al, 2018), the MITRA-FR trial did not show significant differences between the intervention and control groups (Obadia et al, 2018). It is clear that for a successful MitraClip therapy: (i) a multidisciplinary heart team needs to be involved, (ii) procedural techniques need to be optimized, (iii) a better mechanistic understanding of device-host interaction is needed, and (iv) physicians need to perform careful patient selection and individualize treatments in accordance with patient characteristics
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