Transcatheter Repair and Replacement Technologies for Mitral Regurgitation:a European Perspective

PURPOSE OF REVIEW: We aimed to picture the contemporary landscape of available catheter-based repair and replacement solutions for mitral regurgitation (MR) in Europe. RECENT FINDINGS: Edge-to-edge repair remains the dominant technique for transcatheter mitral valve repair especially in the context of secondary mitral regurgitation. Two recent randomized trials reported seemingly contradicting clinical results with transcatheter edge-to-edge repair for patients with heart failure and severe secondary MR. A proportionality framework related to secondary MR was proposed to help explain inconsistencies but requires further research. (In)Direct annuloplasty primarily aims to correct secondary MR; however, the scientific basis seems less robust. One dedicated transcatheter heart valve has the CE mark for mitral valve replacement but requires transapical access. Balloon-expandable transcatheter aortic valve platforms are emerging for transvenous transseptal mitral replacement in the context of mitral annular calcification, a failing surgical mitral bioprosthesis, or annuloplasty. Advanced computed tomography imaging techniques improved pre-procedural planning and introduced the option for modeling and simulation. SUMMARY: Development of a toolbox of catheter-based technologies, complementary imaging modalities, and refined patient selection offer novel perspectives to high-risk patients with primary or secondary MR. Clinical trials are required to help formulate evidence-based guidelines for the management of mitral valve disease

The effect of transcatheter aortic valve implantation on pulmonary artery pressures in a patient suffering from chronic heart failure:A case report

BACKGROUND: Pulmonary hypertension (PH) is most commonly caused by left-sided heart disease and may negatively affect the long-term prognosis and quality of life of patients with chronic heart failure (CHF). CardioMEMS (Micro-Electro-Mechanical-System) allows physicians to monitor pulmonary artery (PA) pressures remotely and optimize heart failure treatment based on haemodynamic parameters, which provides further insight into the effect of valvular interventions. CASE SUMMARY: We present a case of a 61-year-old male patient with an ischaemic cardiomyopathy, poor LV function, moderate to severe mitral regurgitation, and severe aortic valve regurgitation in refractory heart failure. Right heart catheterization and CardioMEMS monitoring revealed severe pulmonary hypertension with mean PA pressures of 55 mmHg and a mean pulmonary capillary wedge pressure of 21 mmHg despite up titration of heart failure medication and sildenafil. Pulmonary and systemic causes of pulmonary hypertension were excluded. After heart team consensus, the patient underwent transcatheter aortic valve implantation (TAVI) which resulted in normalization of PA pressures and a significant improvement of functional performance. DISCUSSION: To the best of our knowledge, this is the first case report describing the direct effects of TAVI on continuous PA pressures in a patient with poor LV function and severe aortic regurgitation. Elective TAVI appeared to be safe and very effective in reverting severe pulmonary hypertension. Most strikingly, drug interventions could not affect the elevated pulmonary pressures, but TAVI corrected the aortic valve insufficiency with normalization of left-sided pulmonary hypertension

Pre-procedural planning of transcatheter mitral valve replacement in mitral stenosis with multi-detector tomography-derived 3D modeling and printing: A case report

Background: Transcatheter mitral valve replacement (TMVR) may be a valuable treatment option for mitral annular calcification and severe mitral stenosis (MS) in patients at high operative risk. Pre-procedural virtual and printed simulations may aid in procedure planning, device sizing, and mitigate complications such as valve embolization or left ventricular outflow tract (LVOT) obstruction. Case summary: We describe a case of TMVR in which multi-detector computed tomography (MDCT) derived, three-dimensional virtual planning and a 3D-printed model of the patients' left heart provided enhanced understanding of an individual patient's unique anatomy to determine feasibility, device sizing, and risk stratification. This resulted in deployment of an adequately sized valve. Post-TMVR LVOT obstruction was treated with LVOT balloon dilatation and percutaneous transluminal septal myocardial ablation. Discussion: Advanced MDCT-derived planning techniques introduce consistent 3D modeling and printing to enhance understanding of intracardiac anatomical relationships and test device implantation. Still, static measurements do not feature haemodynamic factors, tissue, or device characteristics and do not predict device host interaction. Transcatheter mitral valve replacement is feasible in MS when adequately pre-procedurally planned. Multi-detector computed tomography-derived, 3D, virtual and printed models contribute to adequate planning in terms of determining patient eligibility, procedure feasibility, and device sizing. However, static 3D modeling cannot completely eliminate the risk of peri-procedural complications

Large-bore Vascular Closure: New Devices and Techniques

Endovascular aneurysm repair, transcatheter aortic valve implantation and percutaneous mechanical circulatory support systems have become valuable alternatives to conventional surgery and even preferred strategies for a wide array of clinical entities. Their adoption in everyday practice is growing. These procedures require large-bore access into the femoral artery. Their use is thus associated with clinically significant vascular bleeding complications. Meticulous access site management is crucial for safe implementation of large-bore technologies and includes accurate puncture technique and reliable percutaneous closure devices. This article reviews different strategies for obtaining femoral access and contemporary percutaneous closure technologies

Impact of thrombus burden on long-term clinical outcomes in patients with either anterior or non-anterior ST-segment elevation myocardial infarction

Large thrombus burden (LTB) during ST-segment elevation myocardial infarction (STEMI) could translate into worse clinical outcomes. The impact of a LTB in terms of long-term clinical outcomes on different myocardial infarct territories has not yet been fully evaluated. From April 2002 to December 2004, consecutive patients with STEMI undergoing percutaneous coronary intervention with drug eluting stent were evaluated. The study sample was stratified in two groups: anterior STEMI and non-anterior STEMI. LTB was considered as a thrombus larger than or equal to 2-vessel diameters, and small thrombus burden less than 2-vessel diameters. Major adverse cardiac events (MACE) were evaluated at 10-year and survival data were collected up to 15-year. A total of 812 patients were evaluated, 6 patients were excluded due to inadequate angiographic images, 410 (50.9%) had an anterior STEMI and 396 (49.1%) a non-anterior STEMI. Patients with LTB had higher rates of 10-year mortality (aHR 2.27, 95%CI 1.42–3.63; p = 0.001) and 10-year MACE (aHR 1.46, 95%CI 1.03–2.08; p = 0.033) in anterior STEMI, but not in non-anterior STEMI (aHR 0.78, 95%CI 0.49–1.24; p = 0.298; aHR 0.71, 95%CI 0.50–1.02; p = 0.062). LTB was associated with increased 30-day mortality (aHR 5.60, 95%CI 2.49–12.61; p < 0.001) and 30-day MACE (aHR 2.72, 95%CI 1.45–5.08; p = 0.002) in anterior STEMI, but not in non-anterior STEMI (aHR 0.39, 95%CI 0.15–1.06; p = 0.066; aHR 0.67, 95%CI 0.31–1.46; p = 0.316). Beyond 30-day, LTB had no impact on mortality and MACE in both groups. In anterior STEMI, LTB is associated with worse long-term clinical outcomes, this effect was driven by early events. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11239-021-02603-3