Direct Annuloplasty Research Articles

Exercise testing in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve intervention.

Transcatheter tricuspid valve intervention (TTVI) has shown promising results with persistent reduction of tricuspid regurgitation (TR) and improvements in functional class and quality of life (QOL). To analyze the impact of TTVI on maximal and submaximal exercise capacity (SEC). Constant work-rate exercise-time (CWRET) testing reflects SEC, which is more likely to be relevant for daily life activities and provides more differentiated physiological insight into the nature of exercise intolerance. Thus, 30 patients undergoing TTVI (21 direct annuloplasty and 9 edge-to-edge repair) received cardiopulmonary exercise testing (CPET) and CWRET (at 75% of maximum work rate in the initial CPET) before and 3months after TTVI. Patients' age was 80.5 [74.8-82.3] years and 53.3% were female. TR reduction ≥ 2 grades was achieved in 93.3% (TR grade ≤ moderate in 83.3%). Echocardiography revealed improved right ventricular (RV) characteristics with decreased RV basal diameter (47.0mm [43.0-54.3] vs. 41.5mm [36.8-48.0]; p < 0.001) and decreased inferior caval vein diameter. CWRET testing showed a significantly improved SEC (246.5s [153.8-416.8] vs. 338.5s [238.8-611.8] p = 0.001). Maximum oxygen uptake showed a positive trend without statistically significant differences (9.9ml/min/kg [8.6-12.4] vs. 11.7ml/min/kg [9.7-13.3]; p = 0.31). In contrast to the six-minute-walking distance (6MWD), SEC correlated moderately with effective regurgitation orifice area reduction (r = 0.385; p = 0.036), increased cardiac output (r = 0.378; p = 0.039), and improved QOL (r = 387; p = 0.035). Improvements in exercise capacity after TTVI mainly occur in the submaximal rather than in the maximal exercise range and correlate with hemodynamic effects and QOL. This may have a methodological impact on assessment of exercise capacity in these patients.

Performance of Transcatheter Direct Annuloplasty in Patients With Atrial and Nonatrial Functional Tricuspid Regurgitation

BackgroundA novel echocardiography-based definition of atrial functional tricuspid regurgitation (A-FTR) has shown superior outcomes in patients undergoing conservative treatment or tricuspid valve transcatheter edge-to-edge repair. Its prognostic significance for transcatheter tricuspid valve annuloplasty (TTVA) outcomes is unknown. ObjectivesThis study sought to investigate prognostic, clinical, and technical implications of A-FTR phenotype in patients undergoing TTVA. MethodsThis multicenter study investigated clinical and echocardiographic outcomes up to 1 year in 165 consecutive patients who underwent TTVA for A-FTR (characterized by the absence of tricuspid valve tenting, midventricular right ventricular [RV] dilatation, and impaired left ventricular ejection fraction) and nonatrial functional tricuspid regurgitation (NA-FTR). ResultsA total of 62 A-FTR and 103 NA-FTR patients were identified, with the latter exhibiting more pronounced RV remodeling. Compared to baseline, the tricuspid regurgitation (TR) grade at discharge was significantly reduced (P < 0.001 for both subtypes), and TR ≤II was achieved more frequently in A-FTR (85.2% vs 60.8%; P = 0.001). Baseline TR grade and A-FTR phenotype were independently associated with TR ≤II at discharge and 30 days. In multivariate analyses, A-FTR phenotype was a strong predictor (OR: 5.8; 95% CI: 2.1-16.1; P < 0.001) of TR ≤II at 30 days. At 1 year, functional class had significantly improved compared to baseline (both P < 0.001). One-year mortality was lower in A-FTR (6.5% vs 23.8%; P = 0.011) without significant differences in heart failure hospitalizations (13.3% vs 22.7%; P = 0.188). ConclusionsDirect TTVA effectively reduces TR in both A-FTR, which is a strong and independent predictor of achieving TR ≤II, and NA-FTR. Even though NA-FTR showed more RV remodeling at baseline, both phenotypes experienced similar symptomatic improvement, emphasizing the benefit of TTVA even in advanced disease stages. Additionally, phenotyping was of prognostic relevance in patients undergoing TTVA.

Role of preexisting right ventricular remodeling in symptoms and prognosis after transcatheter tricuspid valve repair.

Severe tricuspid regurgitation (TR) is associated with chronic volume overload and right ventricular remodeling (RVR). Transcatheter tricuspid valve repair (TTVr) reduces TR and can improve quality of life (QoL), but the role of preprocedural RVR on TTVr outcomes remains unclear. To investigate the role of RVR on outcomes after TTVr for severe TR. Consecutive patients undergoing TTVr (61% edge-to-edge vs. 39% direct annuloplasty) for severe TR were retrospectively compared by preexisting RVR which was defined as dilation of RV mid-level diameter (> 35mm) according to guidelines. QoL was evaluated using NYHA class, Minnesota Living with Heart Failure Questionnaire (MLHFQ), 36-Item Short Form Health Survey (SF-36), and 6-min walking distance (6MWD) 1-month after TTVr. Mid-term mortality and heart failure (HF) hospitalization were assessed through 1year. RVR was present in 137 of 223 patients (61%). Symptoms and QoL improved equally in both groups: ≥ 1 NYHA class (57% vs. 65% of patients with vs. without RVR, respectively), 6MWD (36% vs. 34%), MLHFQ (81% vs. 69%), and SF-36 (68% vs. 65%) improvement. One-year mortality and HF hospitalization were significantly higher in patients with RVR (24% and 30%, respectively) than in patients without (8% and 13%, both p < 0.05). In multivariable analysis, RVR was independently associated with mortality (HR 2.3, 95%CI (1.0-5.0), p = 0.04) and the combined endpoint of mortality or rehospitalization (HR 2.0, 95%CI (1.1-3.8), p = 0.03). TTVr was associated with significant QoL improvement after 1month, irrespective of RVR. Despite increased mortality and rehospitalization for heart failure, TTVr in the presence of RVR still provides substantial symptomatic benefit for patients with severe TR.

Step-by-step transesophageal echocardiographic guidance for transjugular transcatheter tricuspid valve replacement with a radial force-independent bioprosthesis.

The prohibitive risk of isolated tricuspid valve (TV) surgery encouraged rapid development of a transcatheter solution for tricuspid regurgitation (TR). The favorable results of these devices informed recent guidelines to recommend considering transcatheter treatment of symptomatic secondary severe TR in inoperable patients. Transcatheter TV repair systems usually reduce TR through leaflet approximation and direct annuloplasty. Orthotopic transcatheter TV replacement (TTVR) devices generally rely on radial force and tricuspid leaflet engagement for implantation and stability. The LuX-Valve is a novel radial force-independent orthotopic TTVR device that is operated through the trans-atrial approach. Its radial force-independency is achieved through an interventricular septal anchor tab (septal insertion) and two leaflet graspers (leaflet engagement). Such a unique design makes the intraprocedural imaging different from that of other currently available TTVR systems. The latest generation of this device, the LuX-Valve Plus, comes with a newly designed delivery system through the transjugular approach, which makes the intraprocedural monitoring and adjustment of the device even more complex for successful implantation. However, its unique imaging needs for intra-procedural guidance and post-operative evaluation have not been described before. Therefore, we aimed to elaborate the key steps of transesophageal echocardiography (TEE) to guide this novel procedure. Herein, the primary 2-dimensional (2D) and 3-dimensional (3D) echocardiographic work planes are proposed and the critical steps are emphasized for better communication between imagers and interventionists. The suitability of 2D and 3D echocardiography to guide this procedure is also discussed to increase the flexibility of choice during the implantation.

Comparison of transcatheter leaflet-approximation and direct annuloplasty in tricuspid regurgitation

BackgroundTranscatheter repair emerges as a treatment option in patients with tricuspid regurgitation (TR) and high surgical risk.AimsThis study aimed to compare leaflet-based and annuloplasty-based transcatheter repair in patients with TR.MethodsIn a retrospective analysis consecutive patients undergoing either transcatheter edge-to-edge repair (TEER) or direct annuloplasty (AP) for relevant TR at 2 centers were compared with respect to baseline characteristics, procedural efficacy and safety (death, myocardial infarction, procedure or device-related cardiothoracic surgery, or stroke at 30 days).Results161 patients (57% female, median age 79 [75–82] years) with comparable clinical baseline characteristics in the TEER (n = 87) and AP (n = 74) group were examined. Baseline TR grade was significantly less severe in the TEER compared to the AP group (torrential 9.2 vs. 31.1%, p = 0.001). Technical success and improvement of TR grades were not significantly different across groups. In analysis matched for baseline TR severity, reduction of TR grade to less than moderate was significantly more common in the AP group (47.8 vs. 26.1%, p = 0.031). Major or more severe bleeding occurred in 9.2% of TEER and 20.3% of AP patients (p = 0.049) without any fatal bleedings. Major adverse events (MAE) were similar across groups with four patients (4.7%) in the TEER group and five patients (6.9%) in the AP group (p = 0.733) and 6-month survival did not differ significantly.ConclusionsDifferences observed between patients treated with TEER and AP provide first evidence for tailoring distinct transcatheter treatment techniques to individual patient characteristics.Graphic abstract

Isolated tricuspid regurgitation: a new entity to face. Prevalence, prognosis and treatment of isolated tricuspid regurgitation.

In recent years the tricuspid is no longer considered the "forgotten valve," but nowadays, specialists focused the treatment of tricuspid regurgitation (TR) especially at the time of left heart valve (LHV) surgery, overlooking the emerging entity of isolated TR. Its incidence appears to be rising along with the higher prevalence of atrial fibrillation (AF), intracardiac devices and intravenous drug users. Hence, the aim of the present review is to summarize the available evidences in terms of natural history, clinical presentation and treatment of isolated TR. Tricuspid regurgitation is commonly classified into primary and secondary etiology. Primary or organic TR is relatively uncommon (10%) and may be due to either acquired or congenital diseases. Conversely, secondary or functional TR, caused by dilatation and flattening of the tricuspid annulus along with increase of leaflet tethering due to the remodeling of the right ventricle (RV) has become in last decade an emerging entity. Secondary TR may be due grade progression after left heart valve surgery, to previous TV surgery failure, RV remodeling or permanent AF. Primary TR causes pure volume overload on initially normal right-sided cardiac chambers. Conversely, RV enlargement is the major finding of secondary TR; RV systolic area, RV spherical index and right atrial area were identified as independent factors correlated with TV tethering height. The RV has less muscle mass than the left ventricle, and RV systolic function is therefore more load sensitive. Thus, pulmonary hypertension results in an early fall in RV ejection fraction and associated RV enlargement. An interesting entity is isolated TR related to AF, whose prevalence is estimated to be 14% in recent studies. It is known to cause dilation of the mitral and tricuspid annulus, together with changes in the dynamic mechanisms that govern the variation in area size during the cardiac cycle; as a matter of fact the relative change in TA area was significantly lower in AF (13.5%) than in sinus rhythm (SR) (33.1%). In isolated TR, medical therapy (MT) is indicated only in patients with secondary TR having also severe RV/LV dysfunction or severe pulmonary hypertension. Diuretics are the main MT in case of isolated TR in the presence of right HF in carefully selected candidates, surgery can be performed safely with good long-term survival and it should be considered early at first stages. In the treatment of isolated TR we had two diametrically opposed approaches so far, such as medical therapy, based almost exclusively on diuretics, and surgical therapy. In this scenario, trans-catheter approach is gaining momentum, including repair or replacement treatment. The former sees the use of devices for direct or indirect annuloplasty, or leaflet approximation. The second consists of orthotopic or heterotopic replacement devices (transcatheter tricuspid valve replacement devices). Evidences from randomized studies and longer follow-up will help clarify the best patient selection and treatment strategies.

Leaflet Morphology and its Implications for Direct Transcatheter Annuloplasty of Tricuspid Regurgitation.

Leaflet morphology has been associated with treatment success in edge-to-edge repair of tricuspid regurgitation (TR), but the impact on annuloplasty is unclear. The authors sought to examine the association of leaflet morphology with efficacy and safety of direct annuloplasty in TR. The authors analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband at 3 centers. Leaflet morphology was assessed according to number and location of leaflets by echocardiography. Patients with simple morphology (2 or 3 leaflets) were compared with complex morphology (>3 leaflets). The study included 120 patients (median age 80 years) with≥severe TR. A total of 48.3% of patients had a 3-leaflet morphology, 5% a 2-leaflet morphology, and 46.7% had >3 tricuspid leaflets. Baseline characteristics did not differ relevantly between groups except for a higher incidence of torrential TR grade (50 vs 26.6%) in complex morphologies. Postprocedural improvement of 1 (90.6% vs 92.9%) and 2 (71.9% vs 67.9%) TR grades was not significantly different between groups, but patients with complex morphology had more often residual TR≥3 at discharge (48.2 vs 26.6%; P=0.014). This difference did not remain significant (P=0.112) after adjusting for baseline TR severity, coaptation gap, and nonanterior jet localization. Safety endpoints including complications of the right coronary artery, and technical success did not show significant differences. Efficacy and safety of transcatheter direct annuloplasty using Cardioband are not affected by leaflet morphology. Assessment of leaflet morphology should be part of procedural planning in patients with TR and might help to individually tailor repair techniques to patient anatomy.

Real-Time Monitoring and Step-by-Step Guidance for Transcatheter Tricuspid Annuloplasty Using Transesophageal Echocardiography.

Transcatheter tricuspid valve intervention (TTVI) is a novel alternative to functional tricuspid regurgitation (FTR) for patients with prohibitive surgical risk. Devices have been designed according to different pathophysiological mechanisms of FTR, including ones to achieve an edge-to-edge repair and others aiming at direct annuloplasty. Recently, a transcatheter tricuspid valve repair system mimicking a surgical Kay procedure (K-Clip™ system, Huihe Medical Technology, Shanghai, China) completed its salvage-use trial. The system, which clips the posterior annulus to achieve bicuspidization of the TV, demonstrated acceptable procedural safety and efficacy. Each TTVI system has distinct characteristics for echocardiographic imaging and special consideration for intraoperative guidance. This review focuses on elaborating how two-dimensional and three-dimensional transesophageal echocardiography (TEE) are used in clinical practice to guide K-Clip™ implantation in comparison to other direct annular reduction devices. A limited number of TEE work planes are proposed for the procedure with the aim to provide a steeper learning curve for the echocardiographer and interventionalist while simplifying the implantation steps.

Echocardiography and computed tomography predictors of successful transcatheter direct annuloplasty for mitral regurgitation

Abstract Background Secondary mitral regurgitation (SMR) is associated with adverse outcomes and the optimal treatment modality remains challenging due to extensive variety in the pathology of SMR. Percutaneous direct annuloplasty using the Cardioband system emerged as a promising treatment in selected patients. However, success predictors of this intervention and their association with prognosis remain unclear. Purpose To investigate the role of echocardiographic and computed tomography (CT) data in patients with SMR undergoing percutaneous direct annuloplasty. Methods We retrospectively analyzed patients who underwent catheter-based direct annuloplasty with the Cardioband system for SMR at five tertiary centres in Germany and Switzerland between 2013 and 2020. Patients with procedural success (defined as postprocedural MR grade ≤2+) were compared to those with MR &amp;gt;2+ with respect to baseline echocardiographic data and outcome. Results We included 130 patients (median age 75.5 [71–79], 37% female). Most patients were severely symptomatic (NYHA class III/IV 86.9%), had a median EF of 39 (29–52) with an ischaemic etiology in 39%. Procedural success was achieved in 68%. Procedural time was 178.5 (147.5–214.5) minutes. Patients with and without procedural success differed significantly in measures of MR severity (defined as postprocedural SMR severity (grade, vena contracta (VC), effective regurgitation orifice area and regurgitation volume), annular dilatation (leaflet length, LA sphericity index at end-systole and CT-derived intercommissural distance) and leaflet tethering (tenting area, regurgitation jet direction). In multivariable analysis of echocardiographic parameters including significant measures of annular dilatation and leaflet tethering, predictors of procedural treatment success were tenting area (OR 0.54; 95% CI 0.33–0.98 per mm2, p=0.016) and central regurgitation jet direction (OR 2.96; 95% CI 1.06–8.25, p=0.038). After adding CT data in the multivariable model, intercommissural distance proved to be the most significant predictor (OR 0.96; 0.92–0.99, p=0.009), whereas VC was the only echo predictor (OR 0.84; 0.73–0.98, p=0.03). NYHA class III/IV at last follow up was significantly different between groups, with 34.1% vs. 55.2% of patients with vs. without procedural success, respectively (p=0.04). The combined endpoint of mortality or reintervention at 1 year was significantly lower in patients with procedural success (27% vs. 63%, p=0.002), whereas the association of procedural success with 1-year mortality was of borderline significance (13% vs. 32%, p=0.05). Conclusion Two thirds of patients undergoing transcatheter direct annuloplasty for SMR had procedural success. Careful patient selection by assessment of mitral valve anatomy is helpful to predict procedural success, which translates into less symptom burden and better clinical outcome. Funding Acknowledgement Type of funding sources: None.

Minimally invasive mitral valve surgery after failed transcatheter mitral valve repair in an intermediate-risk cohort.

OBJECTIVESAlthough clinical experience with transcatheter mitral valve interventions is rapidly increasing, there is still a lack of evidence regarding surgical treatment options for the management of recurrent mitral regurgitation (MR). This study provides guidance for a minimally invasive surgical approach following failed transcatheter mitral valve repair, which is based on the underlying mitral valve (MV) pathology and the type of intervention.METHODSA total of 46 patients who underwent minimally invasive MV surgery due to recurrent or residual MR after transcatheter edge-to-edge repair or direct interventional annuloplasty between October 2014 and March 2021 were included.RESULTSThe median age of the patients was 78 [interquartile range, 71–82] years and the EuroSCORE II was 4.41 [interquartile range, 2.66–6.55]. At the index procedure, edge-to-edge repair had been performed in 45 (97.8%) patients and direct annuloplasty in 1 patient. All patients with functional MR at the index procedure (n = 36) underwent MV replacement. Of the patients with degenerative MR (n = 10), 5 patients were eligible for MV repair after removal of the MitraClip. The 1-year survival following surgical treatment was 81.3% and 75.0% in patients with functional and degenerative MR, respectively. No residual MR greater than mild during follow-up was observed in patients who underwent MV repair.CONCLUSIONSMinimally invasive surgery following failed transcatheter mitral valve repair is feasible and safe, with promising midterm survival. The surgical management should be tailored to the underlying valve pathology at the index procedure, the extent of damage of the MV leaflets and the type of previous intervention.

A first dedicated heart valve unit: safe and streamlined patient care for the rapidly growing field of transcatheter heart valve interventions

Abstract Background A dedicated Heart Valve Unit was launched in 2018 to meet the demands of the growing transcatheter heart valve program by optimizing patient care in a single dedicated unit. Purpose To assess the performance of the heart valve unit (all steps of patient care in a single unit with intermediate care facilities) over a conventional approach (preparation on a normal ward, postprocedural intensive care unit (ICU) monitoring and transfer to an additional monitoring ward before discharge) in a high volume center. Methods Retrospective analysis including patients undergoing transcatheter mitral or tricuspid valve repair who were admitted to the Heart Valve Unit (02/2018–01/2020) compared to a conventional patient care approach (02/2016–01/2018). Patients who were already preprocedurally admitted to the ICU or in whom ICU monitoring postprocedurally was mandatory (direct annuloplasty, valve replacement) were excluded. The Heart Valve Unit patient care algorithm is presented in figure 1. We assessed procedural numbers, length of hospital stay, length and need for ICU monitoring, patient transfers between wards and periprocedural safety including in-hospital mortality. Results We observed a 164% increase in procedures (521 vs. 316 in total, 369 vs 282 with mitral valve procedures and 152 vs 34 tricuspid valve procedures) with the launch of the Heart Valve Unit over the 2-year-interval compared to the earlier time period. Length of in-hospital stay was significantly decreased compared to a conventional approach (9±7 vs. 12±11 days, p&amp;lt;0.001). In particular, postprocedural stay could be shortened from 7±7 to 5±6 days (p&amp;lt;0.001). Patients were less transferred between different wards in the Heart Valve Unit setting (p&amp;lt;0.001). Whereas all patients were postprocedurally transferred to the ICU in the conventional setting, only 16% of patients required an ICU bed immediately after the procedure due to complex interventions, intraprocedural events or high-risk comorbidities. The length of stay on ICU declined from 1.4±1.4 to 0.5±2.2 days. Among the patients re-transferred to the Heart Valve Unit directly after the procedure, 2% (10 patients) required an ICU bed in the further course due to hemodynamic instability (2), severe bleeding (4), seizures (1), ventricular fibrillation (1), anaesthetic overhang (1) or after urgent surgery due to a atrioventricular fistula (1). After stabilization, all patients were re-transferred to the Heart Valve Unit and discharged hereinafter. There was no intra-hospital death among these patients. Conclusions A dedicated Heart Valve Unit allows a safe and optimized patient care structure for transcatheter valvular interventions by combining all pre- and postprocedural steps in a single unit, thereby decreasing length of in-hospital stay to meet increasing economic demands. ICU capacity can be specifically used for complex procedures aftercare and complication monitoring. Funding Acknowledgement Type of funding sources: None.

Imaging for transcatheter native tricuspid valve intervention: patient selection, procedural planning and interventional guidance.

There are an increasing number of transcatheter tricuspid valve interventions being performed worldwide using commercially available and investigational devices. Imaging in the pre-procedural and periprocedural period is essential for procedural and clinical success. Echocardiographic-based techniques are particularly important in these procedures, especially for interventional guidance. This review summarizes the current devices in use and how imaging is used for patient selection, procedural planning, and interventional guidance. The most commonly used method of transcatheter tricuspid intervention is edge-to-edge repair using the MitraClip or TriClip devices (Abbott, Santa Clara, CA, USA). Randomized controlled data is pending but observational studies have demonstrated success, especially in the setting of smaller coaptation gaps and adequate transesophageal imaging windows. Direct annuloplasty with the Cardioband (Edwards Lifesciences, Irvine, CA, USA) has also been used in many centers and has demonstrated success when the anatomy and mechanism of tricuspid regurgitation are appropriate for annuloplasty based on imaging evaluation. Lastly, transcatheter valve replacement is becoming more common using several investigational devices and relies heavily on imaging methods to achieve procedural success.

Current devices and interventions in mitral regurgitation

Mitral regurgitation (MR) is the most common valvular disease. With arising incidence in older age, the prevalence of relevant comorbidities inevitably increases. Considering the constantly aging population with high surgical risk, transcatheter therapy of MR is gaining increasing importance. Interventional therapy of either primary or secondary MR represents an alternative to pure drug or surgical therapy. With mitral valve transcatheter edge-to-edge repair, awell-established treatment has evolved in the past two decades. In addition, direct or indirect annuloplasty and ultimately transcatheter mitral valve implantation further expand the armamentarium. The current broad spectrum of interventional therapy options allows for patient-oriented therapy individually targeting different MR pathologies. This review discusses the current landscape of transcatheter therapies for relevant MR.

Transcatheter Treatment of Secondary Tricuspid Regurgitation With Direct Annuloplasty: Results From a Multicenter Real-World Experience.

[Figure: see text].

Transcatheter mitral valve interventions: pre-procedural planning and intra-procedural guidance.

Mitral regurgitation is the most prevalent valve disease worldwide. Percutaneous mitral valve interventions are emerging as alternative options for high-risk patients with severe mitral regurgitation not eligible for conventional surgery. Accurate patient selection is based on a detailed pre-procedural multimodality imaging evaluation. Morphology and functional anatomy of the mitral valve should be evaluated to determine the feasibility of treatments and to identify the best therapeutic approach. The procedures are guided by fluoroscopy, transesophageal echocardiography and fusion imaging, ensuring a continuous communication between the interventionalist and the imaging specialist. The present review will cover the pre-procedural planning and the intra-procedural guidance of the most used transcatheter approaches in the setting of native mitral valve regurgitation: edge to edge repair, percutaneous direct and indirect annuloplasty, transapical beating-heart chordal implantation and transcatheter mitral valve replacement.

What Is the Next Generation of Transcatheter Mitral Valve Repair Devices?

In the evolving scenario of the transcatheter mitral valve repair (TMVr), TMVr devices constitute a rapidly expanding field. The standard classification includes edge-to-edge repair, direct annuloplasty, indirect annuloplasty, chordal/papillary muscular repair, and the others. However, the unknowns and uncertainties to innovate a high-performing device are addressed. In this viewpoint, the authors discuss the potential future of the next generation and the challenges of TMVr devices.

Transseptal direct complete annuloplasty: early experience.

Annuloplasty is a fundamental component of surgical mitral valve repair, and is employed in nearly 100% of repair operations for both primary and secondary mitral regurgitation (SMR). Developing transcatheter techniques to replicate surgical annuloplasty has been the focus of significant innovation and development in recent years. Since many patients are not offered surgery due to high perceived surgical risk, transcatheter approaches will provide new treatment options. In this manuscript, we review technologies which allow transseptal and transcatheter mitral valve (MV) annuloplasty.

Multimodality imaging for preprocedural planning of percutaneous mitral valve repair: a comprehensive review

New transcatheter mitral valve (MV) therapies are now available as alternatives to surgical and medical treatments in patients at high or prohibitive operative risk. Multimodality imaging including echocardiography, cardiac magnetic resonance, and cardiac computed tomography provide complementary information to guide patient and device selection. Morphology and functional anatomy of the MV should be carefully evaluated to determine the feasibility of percutaneous treatment; to identify the best therapeutic approach, either leaflet or annulus or combined; and to predict the probability of procedural success that is crucial for subsequent outcome and should be integrated by comprehensive preprocedural assessment of chamber size, biventricular systolic and diastolic function, valvopathy hemodynamic impact and aortic or peripheral vascular disease. The spectrum of transcatheter options is now wide and encompasses leaflet repair, direct or indirect annuloplasty, and cordal implantation. The aim of this review is to provide an overview on the role of multimodality imaging in the patient selection and preprocedural planning of percutaneous mitral valve repair.

Intraprocedural guidance in percutaneous mitral valve repair

Percutaneous mitral valve intervention is emerging as a valid alternative for patients affected by mitral regurgitation. By addressing the pathophysiology, therapeutic options mainly target the leaflets, annulus or left ventricle. The present review will cover the intraprocedural guidance of the most used approaches, such as edge to edge repair, adjustable transapical beating-heart chordal implantation and percutaneous direct or indirect annuloplasty. Intraprocedural monitoring relies on integration of fluoroscopy and echocardiography, and is based on the continuous communication between the interventional imager and the interventional cardiologist.

Transcatheter Mitral Valve Repair and Replacement: What's on the Horizon?

There are more than 4 million people affected by mitral regurgitation in both the United States and Europe. Prior to the last decade the only options for treatment of MR were medical therapy and open-heart surgery which left many high risk patients with little option once medically optimized. However, we saw a flood in innovative transcatheter mitral valve interventions. As the technologies are refined these new approaches are considerably less invasive and for some high-risk patients may represent a superior option to conventional open-heart surgery. There are 3 main approaches currently being considered for transcatheter mitral valve repair, edge to edge repair, indirect annuloplasty and direct annuloplasty. There have also been large advancements in recent years in transcatheter replacement of the mitral valve. Although many of these devices are under investigation still, we sought to examine the current state of innovative transcatheter mitral valve technologies.