Percutaneous Repair of Mitral Regurgitation with the MitraClip® System

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Abstract

Mitral regurgitation (MR) is most often caused by degenerative disease of the leaflets or develops functionally as a consequence of left ventricular disease (see Figure 1). Patients with severe MR have dyspnea on exertion, fatigue, and, when associated with left ventricular dysfunction or pulmonary hypertension, reduced survival.1 Therefore, surgery to repair or replace the mitral valve is considered to be a class I indication in symptomatic and asymptomatic patients with left ventricular dysfunction. Surgery is also considered reasonable (class IIA) in patients with preserved left ventricular function if the likelihood of a successful repair is high.2

Citation
US Cardiology - Volume 5 Issue 1;2008:5(1):39-40

Pages

Mitral regurgitation (MR) is most often caused by degenerative disease of the leaflets or develops functionally as a consequence of left ventricular disease (see Figure 1). Patients with severe MR have dyspnea on exertion, fatigue, and, when associated with left ventricular dysfunction or pulmonary hypertension, reduced survival.1 Therefore, surgery to repair or replace the mitral valve is considered to be a class I indication in symptomatic and asymptomatic patients with left ventricular dysfunction. Surgery is also considered reasonable (class IIA) in patients with preserved left ventricular function if the likelihood of a successful repair is high.2
However, surgery has a number of limitations. Serious complications occur in up to 20% of patients, and may include peri-operative myocardial infarction (MI), stroke, septicemia, renal failure, respiratory failure, re-operation, and death. Up to 20% of older patients may have additional complications after discharge, prompting re-admission within 30 days.3 Finally, although many surgical series report a high rate of freedom from re-operation after mitral repair, results including overall survival and the rate of recurrent MR are not as good. For instance, in a recent report of 649 consecutive isolated mitral valve repairs for degenerative MR, the freedom from re-operation at 15 years was 92%.4 However, by 15 years 33% of patients had died and recurrent severe MR was present in 30%.4
The rationale for the development of percutaneous techniques to treat MR stems from a desire to reduce the morbidity and mortality of surgical repair or replacement, and to improve results. The various techniques under development include devices inserted into the coronary sinus in order to remodel the adjacent posterior mitral annulus (‘indirect annuloplasty’), more direct annuloplasty and ventricular remodeling devices, leaflet repair, and percutaneous mitral valve replacement.5 The remainder of this article will focus on leaflet repair using the MitraClip® device (Evalve Inc., Menlo Park).

Technique

Percutaneous edge-to-edge repair with the MitraClip device6 is based on a similar surgical approach using suture described by Alfieri.7 In the percutaneous procedure, a 24 French guide catheter (22F in the distal portion) is inserted into the left atrium from the right femoral vein with standard trans-septal techniques. The clip delivery system with the MitraClip attached at its distal end is passed through the guide catheter into the left atrium and steered through the mitral valve using knobs on the proximal handle.

Pages

References
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