Transcatheter Mitral Valve Repair and Replacement | Ten Points to Remember

Maisano F, Alfieri O, Banai S, et al.
The Future of Transcatheter Mitral Valve Interventions: Competitive or Complementary Role of Repair vs. Replacement? Eur Heart J 2015;Apr 13:[Epub ahead of print].

The following are 10 points to remember about the future of transcatheter mitral valve interventions:

  1. Transcatheter mitral valve interventions have been developed to address unmet clinical need and might be a therapeutic alternative to surgery, with an intent to provide symptomatic and prognostic benefit to patients with mitral regurgitation (MR).
  2. Transcatheter mitral valve intervention can be divided into transcatheter repair techniques and transcatheter mitral valve replacement.
  3. Transcatheter mitral valve implantation might be more applicable to a greater proportion of patients than is transcatheter mitral valve repair. Advantages of transcatheter mitral valve implantation include more predictable reduction in MR, greater applicability of a single device, and therefore potentially better ease of training. However, complications might be more catastrophic and less forgiving compared to transcatheter mitral valve repair.
  4. Technical issues in transcatheter mitral valve replacement include an acceptable approach that allows for proper coaxial alignment of the device within the mitral annulus and limitations associated with a transapical approach; stable anchorage of a device within the mitral annulus, which often is dilated and might not be heavily calcified; and avoiding left ventricular outflow tract obstruction and protrusion into the left atrium.
  5. A variety of repair techniques are under development and include devices used on the mitral leaflets, implantation of neochords, and remodeling of the mitral annulus.
  6. The major limitation of transcatheter mitral valve repair is that MR reduction is less predictable, with rare elimination of MR with currently available devices, and the risk that MR will persist or recur after intervention.
  7. In light of advantages and disadvantages of the two approaches, a patient-specific decision-making algorithm likely will be required for the optimal intervention and optimal device choice.
  8. Additional consideration in transcatheter mitral valve intervention includes whether transcatheter delivery might impact tissue degeneration, affecting valve durability, and the role of long-term anticoagulation after intervention.
  9. Inasmuch as surgical mitral valve repair has moved toward a strategy of early intervention (potentially improving patient prognosis as well as reducing symptoms), current indications for transcatheter mitral valve intervention are toward more palliative care in late-stage disease. An excellent safety profile for transcatheter mitral valve interventions would be required in order to consider its use for early intervention in asymptomatic patients with severe MR.
  10. With limited scientific evidence to date, it is difficult to predict the ultimate future role of transcatheter mitral valve intervention.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Mitral Regurgitation

Keywords: Algorithms, Cardiac Surgical Procedures, Choice Behavior, Decision Making, Early Intervention (Education), Heart Atria, Heart Valve Diseases, Mitral Valve, Mitral Valve Insufficiency, Palliative Care, Prognosis

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