Transcatheter Therapies for Valvular Heart Disease
- Ruiz CE, Kliger C, Perk G, et al.
- Transcatheter Therapies for the Treatment of Valvular and Paravalvular Regurgitation in Acquired and Congenital Valvular Heart Disease. J Am Coll Cardiol 2015;66:169-183.
The following are 10 points to remember regarding a recent review of transcatheter therapies for valvular heart disease:
- There are no currently approved transcatheter heart valves (THVs) for the treatment of native valve aortic regurgitation in the United States. There have been off-label uses demonstrating feasibility in high-risk patients. Novel devices are in development in the United States as well as Europe.
- Valve-in-valve (ViV) therapy for degenerated bioprosthetic aortic valves has recently been approved by the Food and Drug Administration (FDA). Procedural success has been reported to be as high as 93%.
- Transcatheter closure of perivalvular leak has been reported both after surgical and transcatheter aortic valve replacements. Aortic perivalvular leaks are generally approached retrograde, most commonly with Amplatzer vascular plugs. Procedural success has been reported at 76.5%.
- Transcatheter therapy of right ventricular outflow tract (RVOT) conduit dysfunction has been demonstrated to be effective over the short- and medium-term. Stent fracture was a concern early in the experience, although pre-stenting of the landing zone prior to Melody THV has significantly reduced rates of stent fracture.
- Techniques and technology for use of THV in patients with native RVOT continue to evolve. There has been off-label use of currently available valves in native RVOTs.
- The MitraClip is the most widely adopted technology for transcatheter mitral valve repair. Registries have shown increased procedural success with decrease in residual mitral regurgitation, improvement of New York Heart Association class, and improved quality-of-life indicators.
- Indirect mitral annuloplasty (using the coronary sinus to reshape the mitral annulus) has not proven successful. Direct annuloplasty, with devices placed trans-septally, has shown promise in early studies. Both incomplete and complete rings are under development.
- Devices for transcatheter mitral valve replacement (TMVR) are also under development. Complexities related to TMVR include large annulus size, asymmetric anatomy, and potential for left ventricular outflow tract obstruction. Four devices have been tested in early clinical trials.
- Mitral bioprosthetic and mechanical perivalvular leaks are generally approached anterograde via trans-septal puncture. Due to unfavorable angulation with a trans-septal approach, transapical access may provide better access to the mitral annulus. Amplatzer occluders are often utilized off-label for closure of paravalvular leak of the mitral valve. In a meta-analysis, 12% of closures were performed with a transapical approach, with a success rate of 100%, as compared with 78.4% with an antegrade trans-septal approach and 66.4% with a retrograde transaortic approach.
- Devices are also in development to treat functional tricuspid regurgitation. There has been experience with off-label ViV procedures for degenerated tricuspid bioprotheses.
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