Advances in transcatheter mitral and tricuspid therapies

BACKGROUND: While rheumatic mitral stenosis has been effectively treated percutaneously for more than 20 years, mitral and tricuspid regurgitation treatment appear as a contemporary unmet need. The advent of transcatheter therapies offer new treatment options to often elderly and frail patients at high risk for open surgery. We aimed at providing an updated review of fast-growing domain of transcatheter mitral and tricuspid technology. MAIN BODY: We reviewed the existing literature on mitral and tricuspid transcatheter therapies. Mitraclip is becoming an established therapy for secondary mitral regurgitation in selected patients with disproportionately severe regurgitation associated with moderate left ventricle dysfunction. Evidence is less convincing for primary mitral regurgitation. Transcatheter mitral valve replacement is a promising emerging alternative to transcatheter repair, for secondary as well as primary mitral regurgitation. But further development is needed to improve delivery. Transcatheter tricuspid intervention arrives late after similar technologies have been developed for aortic and mitral valves and is currently at its infancy. This is likely due in part to previously under-recognized impact of tricuspid regurgitation on patient outcomes. Edge-to-edge repair is the most advanced transcatheter solution in development. Data on tricuspid annuloplasty and replacement is limited, and more research is warranted. CONCLUSION: The future appears bright for transcatheter mitral therapies, albeit their place in clinical practice is yet to be clearly defined. Tricuspid transcatheter therapies might address the unmet need of tricuspid regurgitation treatment

Neo-LVOT and Transcatheter Mitral Valve Replacement: Expert Recommendations

With the advent of transcatheter mitral valve replacement (TMVR), the concept of the neo-left ventricular outflow tract (LVOT) was introduced and remains an essential component of treatment planning. This paper describes the LVOT anatomy and provides a step-by-step computed tomography methodology to segment and measure the neo-LVOT while discussing the current evidence and outstanding challenges. It also discusses the technical and hemodynamic factors that play a major role in assessing the neo-LVOT. A summary of expert-based recommendations about the overall risk of LVOT obstruction in different scenarios is presented along with the currently available methods to reduce the risk of LVOT obstruction and other post-procedural complications

Transcatheter aortic valve implantation: New developments and upcoming clinical trials

Transcatheter aortic valve implantation (TAVI) is a relatively new technique that has been introduced to treat inoperable and high-risk patients with severe aortic stenosis. From its early stages it became apparent that TAVI has tremendous potentialities and thus a considerable effort was made to design new prostheses and advance TAVI technology that would make easier and feasible its application in complex anatomies and in patients with multiple comorbidities. In addition, evidence from randomised control trials have emerged demonstrating that it improves prognosis in inoperable patients (PARTNER trial cohort B) and that it can be considered as an attractive alternative to surgery in patients with a high operative risk (PARTNER trial cohort?A). These encouraging data have motivated the scientific community to organise further trials, which will examine the performance of new devices and explore the feasibility of TAVI in different groups. In this article we review the literature, present the advances in TAVI technology, cite the evidence from the already published studies and discuss the upcoming clinical trials

How should I treat acute valve regurgitation?

BACKGROUND: An 81-year-old male with symptoms of angina and dyspnoea (NYHA 3), a history of coronary bypass surgery, a transaortic peak gradient of 109 mmHg on transthoracic echocardiography and a logistic Euro-SCORE of 21.6 was deemed suboptimal for surgery by a multidisciplinary team and was accepted for TAVI. INVESTIGATION: Preprocedural diameter of the native aortic root was 24.4 mm on transthoracic echocardiography (TTE), 26.9 mm on contrast angiography and 26.8 mm by 30.2 mm on multislice computed tomography (MSCT). DIAGNOSIS: Heavy calcification of the aortic root and coronary arteries by MSCT. TREATMENT: Transcatheter aortic valve replacement with an 29 mm CoreValve prosthesis

Prevalence and prognostic implications of baseline anaemia in patients undergoing transcatheter aortic valve implantation

Aims: TAVI is a minimally invasive alternative to surgical aortic valve replacement or medical therapy in patients with a high or prohibitive operative risk. The clinical significance of baseline anemia and prognostic implications in this patient cohort are unknown. We sought to evaluate the prevalence and prognostic implications of baseline anaemia in patients undergoing transcatheter aortic valve implantation (TAVI) at our institution. Methods and results: One hundred and eighteen consecutive patients who underwent TAVI with the Medtronic Corevalve System (Medtronic Corp., Minneapolis, MN, USA) were included in the analysis. Clinical and biochemical data were prospectively collected before, during and after the procedure. Clinical follow-up was set at one month, one year and yearly thereafter. Anaemia was defined as a haemoglobin level <13 g/dL in men and <12 g/dL in women. Mortality was confirmed by consultation of the civil registry. The prevalence of baseline anaemia was 49%. Anaemic patients undergoing TAVI required more RBC transfusions (3.3±3.1 versus 1.5±2.3; p <0.001) and more frequently experienced a prolonged index hospitalisation exceeding two weeks. For patients with at least 1-year follow up (N=74), mortality at 30 days was no different; however 1-year mortality was significantly higher in the anaemic cohort (44 versus 15%, p=0.006). In a multivariable analysis, baseline anaemia emerged as an independent predictor of 1-year mortality (HR 2.10 [1.06-4.18]). Conclusions: In our series, baseline anaemia is common in patients undergoing TAVI, forecasts a need for more red blood cell transfusions and is associated with increased 1-year mortality