Percutaneous Mitral Valve Repair

Percutaneous Approaches to
Mitral Regurgitation
William F. Armstrong M.D.
Professor of Medicine
University of Michigan
Percutaneous Approaches to
Mitral Regurgitation
• No financial disclosures or conflict of
interest to report.
• With the exception of use of the MitraClip
for degenerative mitral regurgitation in high
risk surgical patients, virtually everything
else is either investigational or an off-label
use of a device.
Mitral Valve Repair:
The Surgical Standard
• Resection of flail / disrupted valvular tissue
• Annular ring to address functional
component and “de-stress” the leaflet tissue
• Chordal repositioning / prosthetic material
• Chordal cutting
Mitral Regurgitation: What can be
Approached Percutaneously
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Balloon valvuloplasty for mitral stenosis
Degenerative mitral regurgitation
Functional mitral regurgitation
Paravalvular leaks
Regurgitation of degenerated bioprosthetic
valve
Implications of Specific Abnormalities
Anatomy
Clinical Implications
Myxomatous valve
May deteriorate, severity of MR may be tricky if not
holosystolic, abrupt worsening of MR, Repairable!!
Flail leaflet
Most often repairable, consider ischemic etiology
Perforation
If small can be patched, most often implies endocarditis
Vegetation
Size vs. embolic risk, degree of leaflet destruction
Apical tethering
Implies functional MR, treat the LV!!, ring may help
Rheumatic appearance Stenosis generally predominates. Risk of thrombus
increased, stratify for balloon valvuloplasty
Cleft valve
Look for primum ASD, repairable
Fibrotic / degenerative Not repairable, often other valve disease as well
Rheumatologic (SLE
etc)
May respond to aggressive therapy. Can be rapidly
destructive. Management may be complicated by
coagulation disorders.
Mitral Valve Anatomy / Function
• The Mitral Apparatus
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Mitral annulus
Mitral leaflets
Chordae tendenae
Papillary muscles
Underlying LV wall
• The leaflets DO NOT
coapt tip-to-tip!!
Mechanisms of Mitral Regurgitation
Functional Mitral Regurgitation:
Dilated Cardiomyopathy
• Is a disease of the LV /
papillary muscles – not the
leaflets
• Seen in dilated and ischemic
cardiomyopathy as well as in
isolated infarct involving the
underlying wall for a papillary
muscle.
• Therapy is directed at the LV,
not the leaflets
• Annuloplasty may be beneficial
• Percutaneous option with the
MitraClip device
Functional MR in Cardiomyopathy
Apical tethering results in
“tip-to-tip” coaptation which
is inherently insufficient
May result in multiple MR
jets
Myxomatous Mitral Valve disease
Posterior Flail on
Background of Myxomatous
Mitral Valve
Myxomatous Mitral Valve
Disease
• Predisposes to spontaneous
chordal rupture and flail
– Posterior leaflet most common
and most easily repaired
– Development of chordal rupture
predicts CHF / worse outcomes
– May result in abrupt dyspnea
• Some patients compensate and
symptoms largely resolve
• Beware of MVP patient with
“URI” that just didn’t go away
Myxomatous Valve with Anterior
and Posterior Flail
Myxomatous Valve with Anterior
and Posterior Flail
Myxomatous Valve with Anterior
and Posterior Flail
The Role of the Echocardiographer in NonSurgical Mitral Procedures
• Identify appropriate candidates
– Mitral anatomy
– Etiology and severity of MR
– Secondary complexities
• Online procedural guidance
• Post procedure followup
Multimodality
imaging with
CT, fluoroscopy,
etc. essential for
planning and
deployment of
devices.
MitraClip System
(Abbott Laboratories)
Currently approved for treatment of
degenerative mitral regurgitation
in high surgical risk patients.
In clinical trial (COAPT)
for functional MR
Percutaneous Approaches to Valve Repair for Mitral Regurgitation Feldman & Young JACC2014
MitraClip Echo Criteria
• “For optimal results..”
– Primary regurgitant jet is
not commisural
– Mitral valve area >4cm2
– Minimal calcification in
grasping area
– No cleft in grasping area
– Flail width <15mm
– Flail gap < 10mm
– LVEF >20%
7mm
3D TEE of MitraClip Candidate
Echocardiographic Predictors of
Procedural Success with the MitraClip
• 300 non-surgical patients
treated with MitraClip for
severe MR
• FMR = 205
• 32 considered procedural
failure
– Implant failure in 11
– >2+ residual MR in 21
Lubos et al JACC: Interventions 2014
Parameter
N=
Failure
EROA>70.8mm2
28
25%
MVOA ≤ 3.0cm2 and
TMPG ≥4mmHG
16
37.5%
Aborted
EROA≤70.8mm2 and
MVOA >3.0cm2
217 <10%
Echocardiographic Predictors of
Procedural Success with the MitraClip
Lubos et al JACC: Interventions 2014
EVEREST II: Five Year Results
• High surgical risk patients
• MR grade 3+ or 4+
• 2:1 randomization to percutaneous MV clip
vs. mitral surgery (178:80)
• Five year follow-up reported
• Endpoints = death, surgery, 3+/4+ MR
Feldman et al. JACC 2015
EVEREST II: Five Year Results
Feldman et al. JACC 2015
EVEREST II: Five Year Results
Mitral Regurgitation
Feldman et al. JACC 2015
NYHA Class
Devices for Indirect and Direct Annuloplasty
Carrilon Device
Accucinch Device
(Cardiac Dimensions, Kirtland WA)
(Guided Delivery Systems, Santa Clara, CA)
Percutaneous Approaches to Valve Repair for Mitral Regurgitation Feldman & Young JACC2014
Percutaneous Mitral Valve Replacement:
Devices in Development / Early Trials
FORTIS
Edwards, Irvine CA
Tendyne
Roseville, MN
Potential anchoring mechanisms
Tiara
Neovasc, British Columbia
Blanke et al. JACC-Imaging, 2015
CardiAQ
Irvine CA
Percutaneous Mitral Valve Replacement:
Mitral Annular Geometry
Blanke et al. JACC-Imaging, 2015
And a Cast of Thousands,
Well Dozens Anyway
Ruiz et al. JACC, 2015
Percutaneous Approaches to
Failed Mitral Bioprostheses
• Apical approach
• Generally use Edwards
Sapien valve (in US)
• Oversize by 10% relative
to the true internal
dimension of the failed
prosthesis
349 VIV, 88 VIR
Dvir D, Euro-PCR May 2015, Paris
Paradis et al. JACC 2015
Paravalvular MR
JASE 2015
Percutaneous Approaches to
Mitral Regurgitation
• MitraClip approved for degenerative MR
– In clinical trial for functional MR
• Valve in valve for prosthetic MR not
approved but gaining acceptance
• Annular approaches for functional MR exist
• Echocardiographic data essential for patietn
identification and procedure monitoring