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Percutaneous Mitral Leaflet Repair: MitraClip Therapy for Mitral Regurgitation

2012 Edition, August 17, 2012

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Active, Most Current

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ISBN: 978-1-84184-966-9
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Product Details:

  • Revision: 2012 Edition, August 17, 2012
  • Published Date: August 17, 2012
  • Status: Active, Most Current
  • Document Language: English
  • Published By: CRC Press (CRC)
  • Page Count: 196
  • ANSI Approved: No
  • DoD Adopted: No

Description / Abstract:


When, 20 years ago, I successfully performed an edge–to-edge repair for the fi rst time on a patient with anterior leafl et segmental fl ail due to primary chordal rupture, I immediately had the perception that such a procedure could have an impact of some relevance in the treatment of patients with mitral regurgitation. As a matter of fact, the functional result in that case was perfect: the newly created double-orifi ce mitral valve was totally competent and the global mitral area was well above 3 cm2 even after implantation of a prosthetic ring. Besides being effective, the edge-to-edge repair was extraordinarily simple. Only few minutes were required to correct a lesion which was considered complex and well known to be historically associated with suboptimal surgical results. At that time many surgeons used to replace the mitral valve when the anterior leafl et was involved in the mechanism producing mitral regurgitation. It was clear to me after that initial experience that a double orifi ce repair could be easily reproducible by every surgeon and therefore be a useful addition to the armamentarium of the techniques used for mitral valve reconstructive surgery.

In the following years our surgical experience expanded and the validity of the concept was repeatedly demonstrated in a variety of clinical subsets. Rigorous follow-up data were collected including echo fi ndings at rest and under exercise, and highly satisfactory mid-term results were reported in patients who received the edge-to-edge repair in conjunction with annuloplasty. Simultaneously the pathophysiology of the operation was extensively studied using computer modeling methods. In well-selected patients without annular dilatation, the prosthetic ring was intentionally avoided without compromising the outcome, at least at mid term.

Our enthusiasm for the procedure, however, was always somehow mitigated by the skepticism of the surgical community. The main criticism was that the edge-to-edge repair was not reproducing the confi guration of a normal mitral valve and was a sort of convenient short cut for those who were unable to properly reconstruct the mitral valve. The occurrence of mitral stenosis was considered a potential problem, and the long-term durability of a double-orifi ce mitral valve was questioned. On the other hand, our referring cardiologists could observe excellent results even in complex cases and had a positive attitude in regard to the edge-to-edge technique. Thanks to the pragmatism of these cardiologists, we have been able to develop one of the largest practices in Europe in the fi eld of mitral valve repair.

The simplicity and the effectiveness of this type of mitral repair were particularly attractive to innovators exploring methods to correct mitral regurgitation percutaneously via transcatheter interventions. Several grasping devices have been developed and tested in animal experiments to approximate the mitral leafl ets and duplicate the Alfi eri stitch. The MitraClip® system currently widely used in the clinical practice is defi nitely the most effective and reproducible.

The role of the percutaneous clip procedure in the clinical practice is still controversial at this point in time. Data from the EVEREST studies and from the rapidly growing clinical experience in Europe provide useful information which can be the basis for some recommendations. It has been defi nitely shown that the clip procedure is relatively safe and generally well tolerated even by patients in poor clinical condition, with serious comorbidities and/or severe left ventricular dysfunction. On the other hand, the clip reduces mitral regurgitation not so effectively as mitral valve surgery, and recurrence or worsening of mitral regurgitation is more likely to occur in the follow-up. It has to be recognized, however, that in sick patients with severe mitral regurgitation, some reduction of mitral regurgitation is providing meaningful clinical benefi t. The applicability of the clip procedure is limited, since precise echocardiographic criteria have to be respected to make a patient eligible. A less rigorous adherence to the criteria of eligibility could allow increased applicability. Mitral valve repair after an unsuccessful clip procedure has been reported in many patients, although the preferred surgical option cannot always be maintained and valve replacement is occasionally necessary.

Considering all the above, the ideal candidate for the clip procedure could be an inoperable or high-risk symptomatic patients with severe mitral regurgitation (organic or functional), fulfi lling the echocardiographic criteria of eligibility. In my opinion, for the time being, patients who can be offered mitral valve surgery with an acceptable risk should not be considered for percutaneous interventions. Along with rapid advancements in technology and progresses in imaging modalities, indications are expected to expand in the near future. Improvements in the fi rst-generation device will take place, and some of the intrinsic limitations of the current system will be abolished. Furthermore, new sophisticated imaging modalities will be introduced and facilitate the procedure. Importantly, an effective catheter-based annuloplasty technique (not available at present) is badly needed to enhance the effectiveness and the durability of the clip procedure.

From a historical perspective, I think that the most important merit of the edge-to-edge technique was to make percutaneous mitral repair possible.