Update on Transcatheter Mitral Valve Replacement

Hensey M, Brown RA, Lal S, et al.
Transcatheter Mitral Valve Replacement: An Update on Current Techniques, Technologies, and Future Directions. JACC Cardiovasc Interv 2021;14:489-500.

The following are key points to remember from this state-of-the-art review on transcatheter mitral valve replacement (TMVR):

  1. Emerging clinical data support the use of transcatheter therapies for significant mitral regurgitation (MR) in select patients.
  2. Currently, edge-to-edge repair is the transcatheter treatment of choice, but many anatomies may not be suitable.
  3. TMVR offers several potential advantages over transcatheter repair, most notably a greater and more sustained reduction in MR post-implantation, but also potential disadvantages.
  4. Echocardiography and computed tomography are essential for patient selection and successful outcome with TMVR. TMVR success is dependent on multimodality imaging, wherein echocardiography is pivotal in preprocedural, intraprocedural, and post-procedural evaluation.
  5. With recent excellent safety, efficacy, and clinical outcomes achieved with transcatheter repair, currently TMVR should be reserved for anatomy that is suboptimal for repair.
  6. The ideal TMVR system would have a safe and simple transseptal delivery, avoid left ventricular outflow tract obstruction, be fully repositionable and recapturable, and demonstrate acceptable durability and repeatability.
  7. Of note, surgical intervention remains the recommended treatment for operative candidates with degenerative MR and is recommended for patients with functional MR undergoing coronary artery bypass grafting or other surgery.
  8. A heart team with expertise in imaging, cardiovascular surgery, and interventional cardiology will be vital to assigning appropriate therapies to appropriate patients. This assessment and subsequent treatment should be performed at high-volume centers, an approach that has demonstrated improved outcomes in the surgical management of mitral valve disease.
  9. The optimal duration of anticoagulation and the potential use of direct oral anticoagulant agents after TMVR also remain a gap in our current evidence base.
  10. TMVR durability is a valid concern, particularly if valves are to be implanted in younger and healthier patients. Further clinical studies are required to establish the long-term outcomes of TMVR including durability.

Clinical Topics: Anticoagulation Management, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging, Mitral Regurgitation

Keywords: Anticoagulants, Cardiac Surgical Procedures, Cardiology Interventions, Coronary Artery Bypass, Diagnostic Imaging, Echocardiography, Heart Valve Diseases, Heart Valve Prosthesis Implantation, Mitral Valve Insufficiency, Secondary Prevention, Tomography, X-Ray Computed

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