Mitral transcatheter edge-to-edge repair: guidance in dogs from the human experience.

Transcatheter tricuspid valve repair: Bringing the forgotten valve into the spotlight

Mitral valve disease is a common heart disease in dogs. The aim of this study was to describe the cases of dogs that underwent mitral valve repair via a V-clamp device and to provide long-term follow-up data on cardiac function after mitral valve repair. Four dogs with mitral valve regurgitation who experienced coughing and dyspnea underwent surgical mitral valve repair between December 2023 and March 2024. The patients were evaluated via transthoracic and transesophageal echocardiography. Echocardiography revealed mitral valve leaflet regurgitation. Mitral valve repair was performed under general anesthesia using a V-clamp device introduced through an introducer wire guide. Echocardiography was conducted at baseline and during the six-month follow-up. Blood analysis results after surgical repair were normal. Follow-up echocardiography revealed no complications related to the procedure, with all dogs demonstrating improved respiratory signs and quality of life after repair. No adverse reactions were reported after surgery. A V-clamp device was used to repair mitral valve regurgitation in four dogs. Mitral valve repair via a V-clamp device is another treatment option for mitral valve disease in dogs.

Percutaneous mitral valve therapy became a reality more than 25 years ago with the first description of balloon valvuloplasty for rheumatic mitral stenosis.1 More recently, percutaneous closure of paravalvular leaks after surgical valve implantation has been shown to have a potential, but limited, role.2–4 However, valvular mitral regurgitation (MR) remains largely the purview of surgery. Recently, the potential for less invasively replicating these successful surgical procedures without the need for thoracotomy or cardiopulmonary bypass has generated considerable interest. For the most part, these new approaches are modeled after established surgical strategies. Percutaneous approaches to mitral repair can be broadly divided into procedures that address the various components of the mitral valve. For purposes of discussion, the mitral valve can be considered to have several component parts: leaflets, subvalvular apparatus (chordate tendinae and papillary muscles), annulus, left atrium, and left ventricle.5 All are integral to the normal function of the mitral valve and each is a potential avenue for repair. Although many such avenues may not lead to an effective surgical option, it may be unwise to dismiss the possibility that others will achieve some measure of success. We briefly review the current percutaneous therapies being developed and evaluated for the management of MR. The current status of various percutaneous therapies is presented in Table 1. View this table: Table 1. Current Status of Percutaneous Mitral Valve Repair Procedures ### Leaflet Repair Complex leaflet repair is currently beyond the reach of a percutaneous approach. However, the relatively simple but, in selected patients, effective “double-orifice” surgical repair initially described by Alfieri and coworkers6 can be reproduced. In the surgical procedure, the free edges of the mitral leaflets are sutured together in the mid portion creating 2 separated orifices. Generally, surgical leaflet repair is combined with implantation of an annuloplasty ring. The surgical literature …

The SAPIEN M3 system for transcatheter mitral valve replacement: A new era begins.

AimsTo compare outcomes of patients with severe mitral regurgitation (MR) after m-TEER and surgery.Methods and resultsPubMed, Scopus, and Google Scholar databases were searched for randomized controlled trials and propensity score matching studies comparing mid-term outcomes of m-TEER vs. surgical valve repair. All-cause of death, rehospitalization for heart failure, mitral reintervention, NYHA class at clinical follow-up and grade ≥ 3 at echocardiographic follow-up were the outcomes of interest. Additional sensitivity analyses were performed to account for heterogeneity. Nine studies (2 RCT and 7 propensity score matching studies) with a total of 23 825 patients (m-TEER group = 11 970; surgery group = 11 855) were included. Surgery and m-TEER were associated with comparable rates of all-cause mortality at a median follow-up of 18 months (RR 1.02, 95%CI 0.77–1.37, P-value 0.87). Surgical repair was associated with a reduced risk of rehospitalization for heart failure (RR 1.70, 95%CI 1.47–1.98, P value < 0.01) and mitral reintervention (RR 3.27, 95%CI 2.49–4.30, P value < 0.01), due to a reduced at least moderate residual MR (RR 6.35, 95%CI 1.43–28.22, P value 0.02).ConclusionIn patients with severe MR, m-TEER resulted in comparable outcomes for all-cause deaths compared to surgery, although the latter was associated with reductions in heart failure rehospitalization, reintervention and MR residual rates at a median 18-month follow-up.

Simple SummaryHeart disease is a leading cause of death for both humans and dogs. Inherited heart diseases, including dilated cardiomyopathy (DCM), account for a proportion of these cases. Human and canine patients with DCM suffer from an enlarged heart that can no longer pump efficiently, resulting in heart failure. This causes symptoms or clinical signs like difficulty breathing, irregular heartbeat, and eventually death. The symptoms or clinical signs of this disease vary in age of onset at the beginning of symptoms, sex predisposition, and overall disease progression. Despite the many similarities in DCM in both species, only a few candidate genes so far have been linked to this disease in dogs versus tens of genes identified in human DCM. Additionally, the use of induced pluripotent stem cells, or engineered stem cells, has been widely used in the study of human genetic heart disease but has not yet been fully adapted to study heart disease in dogs. This review describes the current knowledge on the genetics and subtypes of naturally occurring DCM in dogs, and how advances in research might benefit the dog but also the human patient. Additionally, a novel method using canine engineered stem cells to uncover unknown contributions of mistakes in DNA to the progression of DCM will be introduced along with its applications for human DCM disease modeling and treatment.Cardiac disease is a leading cause of death for both humans and dogs. Genetic cardiomyopathies, including dilated cardiomyopathy (DCM), account for a proportion of these cases in both species. Patients may suffer from ventricular enlargement and systolic dysfunction resulting in congestive heart failure and ventricular arrhythmias with high risk for sudden cardiac death. Although canine DCM has similar disease progression and subtypes as in humans, only a few candidate genes have been found to be associated with DCM while the genetic background of human DCM has been more thoroughly studied. Additionally, experimental disease models using induced pluripotent stem cells have been widely adopted in the study of human genetic cardiomyopathy but have not yet been fully adapted for the in-depth study of canine genetic cardiomyopathies. The clinical presentation of DCM is extremely heterogeneous for both species with differences occurring based on sex predisposition, age of onset, and the rate of disease progression. Both genetic predisposition and environmental factors play a role in disease development which are identical in dogs and humans in contrast to other experimental animals. Interestingly, different dog breeds have been shown to develop distinct DCM phenotypes, and this presents a unique opportunity for modeling as there are multiple breed-specific models for DCM with less genetic variance than human DCM. A better understanding of DCM in dogs has the potential for improved selection for breeding and could lead to better overall care and treatment for human and canine DCM patients. At the same time, progress in research made for human DCM can have a positive impact on the care given to dogs affected by DCM. Therefore, this review will analyze the feasibility of canines as a naturally occurring bidirectional disease model for DCM in both species. The histopathology of the myocardium in canine DCM will be evaluated in three different breeds compared to control tissue, and the known genetics that contributes to both canine and human DCM will be summarized. Lastly, the prospect of canine iPSCs as a novel method to uncover the contributions of genetic variants to the pathogenesis of canine DCM will be introduced along with the applications for disease modeling and treatment.

Transcatheter mitral valve intervention in advanced heart failure

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With Valvular Heart Disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and The Society of Thoracic Surgeons

Mitral regurgitation (MR) has become the predominant mitral valve disease as a result of the regression of rheumatic diseases and the aging of the population. The high prevalence in the elderly of degenerative and ischemic MR implies that MR is currently a public health problem. Recent data suggest that MR has severe outcome implications that are dependent on the degree of regurgitation, both for MR due to organic disease of the mitral valve and MR due to ischemic heart disease. This combination of high prevalence and relatively high risk requires careful examination of therapies applicable to MR. Unfortunately for patients with MR, therapeutic approaches for both medical and surgical treatment have not been evaluated by the state-of-the-art method—ie, by randomized clinical trials. Therefore, observational studies form the basis of our clinical decision-making process, and the quality of evidence is less than optimal. Our assessment of the improvement of outcome provided by various strategies (eg, medical treatment versus untreated observation, surgical treatment versus medical treatment of asymptomatic patients, valve repair versus valve replacement in patients who require surgery) is based on observational studies that have intrinsic limitations. The first implication of this situation is that we need (for a lack of a stronger word) appropriately designed randomized clinical trials comparing various strategies of treatment. The second implication is that it is not surprising that various observational studies, such as that presented by Thourani and colleagues in the present issue of Circulation ,1 may have findings different from each other in accordance with the population examined. Consequently, it is essential to examine the current status of our knowledge and determine how to interpret data that may seem to contradict existing information. See p 298 What does the current literature say about the potential outcome benefit of mitral valve repair for patients …

Systemic inflammatory response syndrome (SIRS) following cardiovascular interventions is associated with adverse events during hospitalization and follow-up. Mitral transcatheter edge-to-edge repair is increasingly utilized for treatment of mitral regurgitation (MR). We investigated whether SIRS following mitral transcatheter edge-to-edge repair may occur and be associated with adverse clinical outcomes. A total of 158 consecutive patients with severe MR undergoing mitral transcatheter edge-to-edge repair were studied. SIRS was defined by leukocytosis (≥12 × 109/L) and fever (≥38 °C) within 48 hours after intervention. Baseline inflammation was measured by absolute neutrophil and lymphocyte counts and neutrophil-lymphocyte ratio. The primary end point of major cardiovascular events was the composite of nonfatal myocardial infarction, nonfatal stroke, and all-cause death. Recurrent MR at follow-up was also recorded. The mean patient age was 80.8±8.8 years. Forty-four (27.9%) developed SIRS. Neutrophil-lymphocyte ratio correlated with onset of leukocytosis and fever (P=0.04). During a median follow-up of 12.5 (5.4-17.4) months, the primary end point occurred in 27 (17.1%) patients (6 myocardial infarction, 5 strokes, and 16 deaths). Patients with SIRS more often had severe MR (79.5% versus 62.7%, P=0.02) at follow-up. After adjustment for pertinent variables, SIRS (HR 2.73 [95% CI, 1.08-6.86]; P=0.03) was independently associated with major cardiovascular events. SIRS after mitral transcatheter edge-to-edge repair is a strong independent predictor of major cardiovascular events. Closer follow-up is warranted because patients with SIRS have more severe MR at follow-up.

BackgroundLeft ventricular (LV) rupture is an extremely rare but possible complication after mitral transcatheter edge-to-edge repair (M-TEER). We describe a delayed LV rupture after M-TEER that was successfully treated with surgical repair.Case summaryAn 83-year-old Asian male with congestive heart failure was referred for treatment of severe mitral regurgitation (MR) due to A1/A2 segment prolapse with abnormally hypertrophied anterior papillary muscle. The patient was at high surgical risk, and M-TEER with MitraClip (Abbott Vascular, Minneapolis, MN, USA) was performed. During the procedure, an NT clip became entangled between the hypertrophied papillary muscle and the LV inferolateral wall. After disentangling the clip, we aimed the clip for a second attempt slightly towards the medial side and inserted it into the LV, avoiding interference with the subvalvular apparatus or LV wall. Grasping in this position significantly reduced MR to mild. The patient was initially stable, but sudden cardiac arrest occurred 75 min post-procedure, and subsequent echocardiography revealed massive pericardial effusion. Emergent sternotomy revealed a tear at the LV basal inferolateral wall just behind the anterior papillary muscle. Surgical patch repair and mitral valve replacement were performed, and the patient was discharged without neurological sequelae.DiscussionThe entrapment of the clip between the hypertrophied papillary muscle and the hypercontractile LV wall may have caused a crack in the LV wall, disrupting the endocardium. In elderly patients with primary MR, especially those with commissural lesions and limited LV space, clinicians should be cautious of LV rupture even after the procedure.

1-Year Outcomes for Transcatheter Repair in Patients With Mitral Regurgitation From the CLASP Study.

Limited data exist regarding the impact of mitral annular calcification (MAC) on outcomes of transcatheter edge-to-edge repair for mitral regurgitation (MR). We retrospectively analyzed 968 individuals (median age, 79 [interquartile range, 70-86] years; 60.0% males; 51.8% with functional MR) who underwent an isolated, first-time intervention. Stratified by MAC extent per baseline transthoracic echocardiogram, the cohort was assessed for residual MR, functional status, all-cause mortality, heart failure hospitalizations, and mitral reinterventions post-procedure. Patients with above-mild MAC (n=101; 10.4%) were older and more likely to be female, exhibited a greater burden of comorbidities, and presented more often with severe, primary MR. Procedural aspects and technical success rate were unaffected by MAC magnitude, as was the significant improvement from baseline in MR severity and functional status along the first postprocedural year. However, the persistence of above-moderate MR or functional classes III and IV at 1 year and the cumulative incidence of reinterventions at 2 years were overall more pronounced within the above-mild MAC group (significant MR or functional impairment, 44.7% versus 29.9%, P=0.060; reinterventions, 11.9% versus 6.2%, P=0.033; log-rank P=0.035). No link was demonstrated between MAC degree and the cumulative incidence or risk of mortality and mortality or heart failure hospitalizations. Differences in outcomes frequencies were mostly confined to the primary MR subgroup, in which patients with above-mild MAC also experienced earlier, more frequent 2-year heart failure hospitalizations (20.8% versus 9.6%; P=0.016; log-rank P=0.020). Mitral transcatheter edge-to-edge repair in patients with and without above-mild MAC is equally feasible and safe; however, its postprocedural course is less favorable among those with primary MR.

BackgroundThe MitraClip (Abbott), a percutaneous edge-to-edge mitral valve (MV) repair device, is the only approved device in Japan for mitral transcatheter edge-to-edge repair (M-TEER) therapy to treat primary and secondary mitral regurgitation (MR). Outcomes of the fourth-generation M-TEER system, featuring independent grasping, improved clip deployment, and 4 clip sizes with wider and longer clip arms, have not been reported in Japan. ObjectivesThis study evaluates the 1-year safety and effectiveness of the fourth-generation M-TEER system in Japan to treat MR in a contemporary, real-world setting. MethodsEXPAND G4 is a prospective, single-arm, international, postmarket study. One-year outcomes from subjects treated in Japan include MR severity (assessed by an echocardiography core laboratory), all-cause mortality, heart failure hospitalization, NYHA functional class, and quality of life. ResultsA total of 95 subjects were treated with the fourth-generation M-TEER system at 7 centers in Japan. Subjects in Japan had a higher surgical risk with smaller cardiac dimensions and MV areas. A 100% implant rate was achieved with a large proportion of standard clips (NT/XT). At 1 year, there was significant and sustained MR reduction (99%, 77/78 MR ≤1+), with low MV mean gradients (2.9 ± 1.8 mm Hg) and improved functional capacity (96.2%, 75/78 NYHA functional class I/II). The 1-year rates of all-cause mortality and heart failure hospitalizations were 9.5% and 18.9%, respectively, with low major and device-related adverse event rates. ConclusionsThis first report of echocardiography core laboratory–assessed outcomes with the fourth-generation M-TEER system in Japan shows that excellent and durable technical and clinical outcomes can be achieved with M-TEER in Japan. (MitraClip EXPAND G4 Study; NCT04177394)