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Percutaneous Mitral Valve Interventions: Evaluation, Pitfalls, and Complications


LEARNING OBJECTIVES

  • 1.

    Review the indications for transcatheter mitral valve therapies according to American Heart Association/American College of Cardiology and European Society of Cardiology guidelines.

  • 2.

    Review scoring systems for the assessment of favorable anatomy for mitral valve balloon valvuloplasty.

  • 3.

    Review favorable and unsuitable anatomy for transcatheter mitral valve edge-to-edge repair for primary and secondary mitral regurgitation.

  • 4.

    Discuss the importance of multidisciplinary heart team approach and optimization of medical therapy prior to mitral valve procedures.

  • 5.

    Review common complications for transcatheter mitral valve procedures with emphasis on device-specific complications, in particular edge-to-edge repair and transcatheter mitral valve replacement.

INTRODUCTION

The field of transcatheter mitral valve interventions began with percutaneous mitral balloon valvuloplasty (PMBV) for mitral stenosis in the early 1980s. Since then, there has been a technological revolution that has permitted the treatment of regurgitant lesions. Transcatheter edge-to-edge repair (TEER) of the mitral valve with MitraClip (Abbott Vascular; Abbott Park, IL, USA) was first performed in 2003 and is now approved by the U.S. Food and Drug Administration (FDA) for the treatment of mitral regurgitation (MR) in selected patients. In addition, the success of transcatheter aortic valve replacement (TAVR) sparked interest in transcatheter mitral valve replacement (TMVR), which is now undergoing investigational assessment with a variety of devices. The major lesson learned throughout the journey of percutaneous mitral valve interventions is that appropriate patient selection is key for procedural success, especially given the complexity of the mitral valve apparatus and the heterogeneity of mitral valve diseases. Patient selection not only requires a global assessment of mitral valve anatomy, the underlying mechanism of mitral valve disease, the structure and function of the left ventricle, and patient comorbidities, particularly in the elderly and frail patients, but also the unique safety, efficacy, and results of specific devices and approaches.

PATIENT SELECTION AND EVALUATION

Percutaneous Mitral Balloon Valvuloplasty

According to the American Heart Association (AHA)/American College of Cardiology (ACC) and the European Society of Cardiology (ESC) guidelines, PMBV is indicated for the treatment of symptomatic severe mitral stenosis (mitral valve area <1.5 cm 2 ) with favorable mitral valve anatomy and in the absence of any contraindications (AHA/ACC Class Ia, ESC Class Ib). , PMBV can be considered for asymptomatic patients with severe mitral stenosis and an aortic valve area of less than 1 cm 2 ( Table 25.1 ). PMBV treats mitral stenosis through separation of the fused commissures with subsequent increase in the mitral valve orifice area. Transesophageal echocardiography (TEE) is necessary to evaluate the anatomy of the mitral valve and the presence of contraindications ( Fig. 25.1 ). Contraindications include the presence of left atrial thrombus, massive or bicommissural calcification, more than mild MR, and concomitant other valvular diseases or severe coronary artery disease requiring surgical intervention. Multiple scoring systems exist for the assessment of the suitability of mitral valve morphology for PMBV, the most commonly used one is the original Wilkins score. The Wilkins system assigns a score of 1 to 4 for each leaflet’s mobility, thickening, calcification, and subvalvular thickening based on the transthoracic echocardiogram. A stenotic mitral valve with a Wilkins score of more than 8 is considered to have an unfavorable anatomy for PMBV due to advanced leaflet deformity, and a mobile mitral valve with limited thickening is more suitable for the procedure. Among patients with unsuitable anatomical features and high surgical risk, a multidisciplinary approach is recommended, as some of these patients may be suitable for PMBV if the surgical risk is high or prohibitive. ,

TABLE 25.1
Summary of Recommendations for Transcatheter Mitral Valve Therapies According to the 2020 ACC/AHA Guidelines for the Management of Valvular Diseases
Percutaneous Mitral Valve Interventions ACC/AHA Class, Level of Evidence
Percutaneous Mitral Balloon Valvuloplasty
Symptomatic severe mitral stenosis (MVA<1.5 cm 2 ), favorable anatomy, and absence of contraindications I, A
Asymptomatic severe mitral stenosis (MVA<1.5 cm 2 ), favorable anatomy, absence of contraindications, and elevated pulmonary pressures (PASP >50 mm Hg) IIa, B-NR
Symptomatic severe mitral stenosis (MVA<1.5 cm 2 ), suboptimal anatomy, and absence of contraindications IIb, B-NR
Transcatheter Mitral Valve Repair for Primary Mitral Regurgitation
Symptomatic chronic severe primary mitral regurgitation, favorable anatomy, life expectancy >1 year, and prohibitive surgical risk IIa, B-NR
Transcatheter Mitral Valve Repair for Secondary Mitral Regurgitation
Chronic severe secondary mitral regurgitation, persistent symptoms despite optimal GDMT, and approrpriate anatomy IIa, B-R
ACC, American College of Cardiology; AHA, American Heart Association; GDMT , Guideline directed medical therapy; MVA, mitral valve area.

Fig. 25.1, Transesophageal echocardiography images of a patient with severe mitral stenosis undergoing evaluation for percutaneous mitral balloon valvuloplasty. (A) Transesophageal echocardiography 2-chambers view shows mitral valve leaflets and subvalvular thickening without evidence of significant leaflets calcification. (B) 4-chamber view demonstrates again the leaflets and subvalvular thickening. (C) There is absence of mitral regurgitation and left atrial thrombus that would preclude eligibility for mitral balloon valvuloplasty.

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