Current Transcatheter Repair Strategies for Mitral Regurgitation

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Mitral regurgitation (MR) is the most prevalent form of valvular heart disease. Its major causes are primary mitral leaflet abnormalities (valve prolapse, healed endocarditis, or rheumatic disease), primary myocardial disease (functional MR), and ischemic disease. Even with severe MR, affected individuals may remain asymptomatic for long periods of time.1 The early, compensated state of MR is characterized by atrial and ventricular remodeling into larger, more compliant chambers; initially, this avoids pulmonary artery hypertension and maintains normal cardiac output. At a histological/biochemical level, this process has been characterized in canine models by increased myocardial matrix metalloproteinase activation with significant degradation of the extracellular matrix.2,3 With disease progression, clinical heart failure develops as a result of volume overload of the left ventricle, eventually leading to irreversible myocardial dysfunction and death unless the valve is repaired or replaced.4,5
Surgical correction of MR is recommended for asymptomatic patients before significant left ventricular dilatation or left ventricular systolic dysfunction occur, and is also recommended for patients after symptoms have developed.6 Current operative strategies include annuloplasty, leaflet repair (reshaping, edge-to-edge approximation, pericardial patch), leaflet mobilization, or chordal repair and valve replacement.7 In an effort to develop less invasive treatment options and to circumvent the necessity of cardiopulmonary bypass for mitral valve repair/replacement, efforts have recently focused on the development of transcatheter techniques that mimic these surgical approaches.

Catheter-based Edge-to-edge Repair

Edge-to-edge—or Alfieri—surgical repair for the treatment of MR initially consists of suturing the middle scallop (A2) of the anterior leaflet to the middle scallop (P2) of the posterior leaflet, creating a ‘double-orifice’ mitral valve.8–11 This technique offers a simple solution to the common problem of mitral valve prolapse, and has served as the basis for edge-to-edge transcatheter MR repair. Using a trans-septal approach with a guiding catheter and a smaller delivery catheter within it, a mitral clip (MitraClip, Evalve, Menlo Park, CA) is delivered to the ventricular surface of the mitral valve in the open position. The clip is then withdrawn, grasping the central anterior and posterior leaflets, and closed; this approximates the A2 and P2 scallops (see Figure 1).

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References
  1. Rosen SE, Borer JS, Hochreiter C, et al., Am J Cardiol, 1994;74:374–80.
    Crossref | PubMed
  2. Stewart JA,Wei C, Brower GL, et al., J Mol Cell Cardiol, 2003;35:311–19.
    Crossref | PubMed
  3. Urabe Y, Mann DL, Kent RL, et al., Circ Res, 1992;70:131–47.
    Crossref | PubMed
  4. Starling MR, Circulation, 1995;92:811–18.
    Crossref | PubMed
  5. Ling LH, Enriquez-Sarano M, Seward JB, et al., N Engl J Med, 1996;335:1417–23.
    Crossref | PubMed
  6. Bonow et al.,Circulation, 2006;114(5):e84–e231.
    Crossref | PubMed
  7. Fucci C, Sandrelli L, Pardini A, et al., Eur J Cardiothorac Surg, 1995;9:621–7.
    Crossref | PubMed
  8. Alfieri O, Maisano F, DeBonis M, et al., J Thorac Cardiovasc Surg, 2001;122:674–81.
    Crossref | PubMed
  9. Maisano F, Scheuder JJ, Oppizzi M, et al., Eur J Cardiothorac Surg, 2000;17:201–15.
    Crossref | PubMed
  10. Umana JP, Salehizadeh B, DeRose JJ, et al.,Ann Thorac Surg, 1998;66:1640–46.
    Crossref | PubMed
  11. Privitera S, Butany J, Cusimano RJ, et al.,Circulation, 2002;106;e173–e174.
    Crossref | PubMed
  12. Feldman T,Wasserman HS, Herrmann HC, et al., J Am Coll Cardiol, 2005;46:2134–40.
    Crossref | PubMed
  13. Feldman T, Clin Cardiol, 2007;30:416–17 (abstract).
  14. Harris KM, Sundt TM III, Aeppli D, et al., Ann Thorac Surg, 2002;74:1468–75.
    Crossref | PubMed
  15. Bolling SF, J Heart Valve Dis, 2002;11(Suppl. 1):S26–S31.
    PubMed
  16. Shinbane JS, Lesh MD, Stevenson WG, et al., Am Heart J, 1998;135:93–8.
    Crossref | PubMed
  17. Maniu CV, Patel JB, Reuter DG, et al., J Am Coll Cardiol, 2004;44(8):1652–61.
    Crossref | PubMed
  18. Kaye DM, Byrne M, Alferness C, et al., Circulation, 2003;108:1795–7.
    Crossref | PubMed
  19. Bailey LR, Luna-Guerra J, Sheahan B, et al.,Am J Card, 2002;90:39H.
  20. Webb JG, Harnek J, Munt B, et al., Circulation, 2006;113:851–5.
    Crossref | PubMed
  21. Kuck K,Webb J, Harnek J, et al., Am J Card, 2007;100(8):58L (abstract).
  22. Siminiak T, Jerzykowska O, Kalmucki P, et al., Am J Card, 2007;100(8):58L (abstract).
  23. Daimon M, Shiota T, Gillinov AM, et al., Circulation, 2005;111;2183–9.
    Crossref | PubMed
  24. Mainu CV, Patel JB, Reuter DG, et al., J Am Coll Cardiol, 2004;44: 1652–61.
    Crossref | PubMed
  25. El Maasarany S, Ferrett CG, Firth A, et al.,Europace, 2005;7:475–81.
    Crossref | PubMed
  26. Maselli D, Guarracino F, Chiaramonti F, et al., Circulation, 2006;114:377–80.
    Crossref | PubMed
  27. Tops LF, Van de Veire NR, Schuijf JD, et al.,Circulation, 2007;115:1426–32.
    Crossref | PubMed
  28. Rogers JH, Macoviak JA, Rahdert DA, et al., Circulation, 2006;113:2329–34.
    Crossref | PubMed
  29. Palacios F, Condano JA, Brandi S, et al., Catheter Cardiovasc Interv, 2007;69:515–18.
  30. Kono T, Sabbah HN, Rosman H, et al., J Am Coll Cardiol, 1992;7:1594–8.
    Crossref | PubMed
  31. Boltwood CM, Tei C,Wong M, et al., Circulation, 1983;68:498–508.
    Crossref | PubMed
  32. McGee EC, Gillinov AM, Blackstone EH, et al., J Thorac Cardiovasc Surg, 2004;128:916–24.
    Crossref | PubMed
  33. Lachmann J, Shirani J, Plestis KA, et al., Curr Cardiol Rep, 2001;3:241–6.
    Crossref | PubMed
  34. Trehan N, Mishra YK, Mittal S, IJCTVS, 2003;19:2 (abstract).
  35. Inoue M, McCarthy PM, Popovic ZB, et al., Heart Surg Forum, 2004;7:E117–21.
    Crossref | PubMed
  36. Grossi EA, Saunders PC,Woo YJ, et al., Ann Throac Surg, 2005;80:1706–11.
    Crossref | PubMed
  37. Mishra YK, Mittal S, Jaguri P, et al., Ann Thorac Surg, 2006;81:42–6.
    Crossref | PubMed