5.1 / IAGS 2019
Session 5: Structural Session 2 – Mitral & Triscuspid
Transcatheter Mitral Valve Repair Devices: Building the Toolbox, But Do They Compete With Surgery and Can They Deal With MAC?
Problem Presenter: Molly Szerlip, MD
Statement of problem or issue
Mitral valve repair by standard surgical techniques is the gold standard for treatment of patients with primary (degenerative) mitral regurgitation. This is due to the fact that surgical treatment can be curative, durable, and symptom eliminating, as well as being performed using minimally invasive techniques (i.e. port access or robotic). They however still require the heart lung machine and multiple days in the hospital with a longer recovery time. Surgical treatments are variable amongst operators/hospitals and consist of multiple different techniques. As technology progresses, patients are demanding less invasive options for these treatments that require shorter recovery and no heart lung machine as well as achieving similar outcomes to surgery.
Gaps in knowledge
Primary mitral regurgitation is a variable disease with multiple etiologies and disease processes. This in turn results in multiple different techniques for repair that may not be standardized across institutions and operators. One device demonstrating benefit does not translate into a class effect. For instance, the mitral clip shows benefit but that doesn’t mean that cardioband will. Furthermore, currently only 1 device can be used at one time whereas in surgery mutliple techniques can be used (i.e. band with chords). Lastly, these new devices are very expensive, more so than traditional surgery.
Possible solutions and future directions
There are multiple transcatheter/percutaneous devices that are in clinical trials to address this disease process. With these trials, we are learning more about primary mitral regurgitation and as a result learning about secondary mitral regurgitation as well. It is clear that one device may not be enough and that multiple devices may be needed to obtain a surgical result such as a transcatheter band with a leaflet repair device. There are not as many mitral surgeons as there are coronary or aortic valve surgeons, and this often leads to incorrect treatment of the mitral valve. For degenerative disease, many surgeons are still replacing the valve instead of repairing. Since this is not the appropriate treatment option, transcatheter mitral repair would be a more correct option with quicker recovery. There also needs to be more emphasis on the heart team approach like TAVR has used. There needs to be more discussions with the patients by both the surgeons and the cardiologists to make sure the correct treatment is given. There also needs to be a bigger push for education of both the patients and the referring physicians to recognize severe mitral regurgitation, and to know who and where to refer. Cardiologists need to better quantify and describe the type of mitral regurgitation on echo to help with the treatment plan. For functional mitral regurgitation, heart failure doctors need to be involved with the treatment regimen so that patients get optimal goal directed medical therapy. As CoAPT showed us, GDMT actually works, and patients did not need to undergo transcatheter mitral repair therapy. As far as mitral annular calcification, there does not seem to be a role for mitral repair devices; however, there may be a role for mitral valve replacement devices.