Transcatheter Mitral Valve Replacement: Current Evidence and Concepts

Over the past decade, several transcatheter devices have been developed to address the treatment of severe mitral regurgitation (MR) in patients at high surgical risk, mainly aimed at repairing the native mitral valve (MV). MV repair devices have recently been shown to have high efficacy and safety. However, to replicate promising trial results, specific anatomical and pathophysiological criteria have to be met and operators need a high level of experience. As yet, the longer-term durability of transcatheter MV repair remains unknown. Transcatheter MV replacement (TMVR) might be a treatment option able to target various anatomies, reliably abolish MR, and foster ease of use with a standardised implantation protocol. This review presents upcoming TMVR devices and available data and discusses how TMVR might further advance the field of transcatheter treatment of MR

Transcatheter mitral valve repair

Transcatheter therapy has emerged as an option for the treatment of mitral regurgitation (MR) for selected, predominantly high-risk, patients. Most transcatheter procedures are less invasive modifications of existing surgical approaches with a lower procedural risk. The complex anatomy of the mitral valve and varying mechanisms of MR has led to a range of devices being developed that vary in their indications, complexity of delivery, efficacy, and potential complications. This chapter will discuss the treatment of MR using transcatheter leaflet repair and mitral annuloplasty techniques. Transcatheter mitral valve replacement is covered separately. The aetiology and mechanism of MR will determine the type of therapy possible. In primary MR, a leaflet disease, mitral leaflet plication using the edge-to-edge technique, MitraClip is the only currently available percutaneous device. Leaflet repair is also possible using the Neochord device, but this requires a transapical surgical approach with insertion of neochordae that are anchored to the left ventricular apex. In secondary MR, which may be ischaemic or non-ischaemic, the mitral leaflets are usually normal but are tethered and tented secondary to changes in left ventricular size, geometry, and annular size. Transcatheter repair options for secondary MR include MitraClip and percutaneous annuloplasty devices (direct and indirect). It is worth noting that a number of new transcatheter devices are currently in development and the field is likely to expand significantly in the future as these technologies develop.

Management of Tricuspid Regurgitation: The Role of Transcatheter Therapies

Surgical treatment is the gold standard treatment of functional tricuspid regurgitation (FTR) but this carries high risks of morbidity and mortality. Percutaneous procedures are an attractive alternative to surgery for selected patients deemed to be high-risk surgical candidates. A number of tricuspid transcatheter devices have been developed to treat FTR, but at present, evidence of their efficacy and safety is scarce. Preliminary data have shown promising results, but ongoing and future studies will provide a clearer picture of the benefits of these new techniques.

Comparison of surgical vs. non-surgical closure procedures for secundum atrial septal defect

Backgi-ound Surgery has been the standard therapy for secundumatrial septa! defect (ASD) closure, but it has significant associatedmorbidities related to st ernotomy, car diopulmonary bypass,complications, residual scars, and trauma. A less invasive nonsurgicalapproach with transcatheter devices was developed toocclude ASD. Amplatzer® septa! occluder (ASO) is a commondevice in transcatheter closure.Objective To compare two secundum ASD closure procedures,transcatheter closure by ASO and surgical closure, in terms ofefficacy, complications, length of hospital stay, and total costs.Methods A retrospective analysis was performed on childrenwith secundum ASD admitted to the Cardiology Center ofCipto Mangunkusumo Hospital from January 2005 to December2011. Patients received either transcatheter closure with ASOor surgical closure procedures. Data was obtained from patients'medical records.Results A total of 112 secundum ASD cases were included in thisstudy, consisting of 42 subjects who underwent transcatheter closureprocedure by ASO and 70 subjects who underwent surgical closureprocedure. Procedure efficacies of surgery and ASO were not significantlydifferent (98.6% vs 95.2%, respectively, P= 0.555). However,subjects who underwent surgical procedures had significantly morecomplication s than subjects who underwent transcatheter closureprocedure (60% vs 28.6%, respectively, OR 1.61; 95%CI 1.19 to2.18; P= 0.001). Hospital stays were also significantly longer forsurgical patients than for transcatheter closure patients (6 days vs2 days, respectively, P< 0.0001). In addition, all surgical subjectsrequired intensive care. Transcatheter closure had a mean total costof 52.7 (SD 6.7) million Rupiahs while the mean cost of surgery was47 (SD 9.2) million Rupiahs (P< 0.0001) . Since the ASO devicecost represented 58% of the total cost of transcatheter closure, themean cost of transcatheter closure procedure without the deviceitself was less costly than surgery.Conclusion Transcatheter closure using ASO has a similar efficacyto that of surgical closure procedure. However, subjects whounderwent transcatheter closure have lower complication ratesand shorter length ofhosp ital stays than subjects who had surgery,but transcatheter closure costs are higher compared to the surgicalprocedure.