Catheter Management Of Mitral Regurgitation

Article Author:
Kristen Brown
Article Editor:
Michael Lim
Updated:
9/18/2019 4:26:32 PM
PubMed Link:
Catheter Management Of Mitral Regurgitation

Introduction

Mitral regurgitation (MR) is one of the most common valvular abnormalities. Medical management along with regular surveillance is the recommendation for mild MR. Traditionally, management of severe disease has been surgical intervention More recently, studies have proven that the transcatheter approach is falling in favor. The edge-to-edge leaflet repair device is a minimally invasive catheter-based therapy that uses a clip to bring together the tow flailing leaflets which results in decreased or resolution of regurgitation. This chapter will discuss in detail primary and secondary mitral regurgitation, non-invasive catheter management options including indications, contraindication, procedural technique, and complications.  

Anatomy

The mitral valve (MV) apparatus is an anatomically complex structure that includes the ventricle, papillary muscles, chordae tendineae, leaflets, and the mitral annulus. Alteration to any of these can lead to the development of mitral regurgitation (MR).[1] Mitral regurgitation is when the valve does not close completely, which allows for backward blood flow leading to a number of different problems. The two types of MR are primary or secondary. Primary mitral regurgitation is degenerative valve disease, while secondary mitral valve regurgitation is characterized as functional myocardial disease. MR is further classified further as mild, moderate, and severe. Severe (or moderate-severe) MR is currently only recommended for catheter management. Echocardiogram is the primary tool used to assess the severity of MR. Severe MR is described as having a color flow jet that may be central and large (>6 cm or >30 percent of left atrial area) or smaller if eccentric, encircling the left atrium. Pulmonary vein flow may show systolic blunting or systolic flow reversal, vena contracta width =0.5 cm measured in the parasternal long axis view, a regurgitant volume of =45 mL/beat, regurgitant fraction =40 percent, and/or regurgitant orifice area =0.30 cm^2 according to the American College of Cardiology and American Heart Association. [2] Several interventions exist to treat severe MR including surgical and non-surgical. If left untreated severe MR can lead to fatal sequelae including heart failure.

Indications

Currently, the edge-to-edge leaflet repair device is the only recommended intervention to treat MR are limited, but there are many emerging technologies including but not limited to neo-cords, transcatheter mitral valve repair, and rings. At present, the following are the indications for this device:

  • Moderate to severe primary MR (3 to 4+)
  • Severely symptomatic heart failure
  • Non-surgical candidate
  • Repairable anatomy
  • Good life expectancy

Contraindications

There are very few contraindications to catheter intervention with the edge-to-edge leaflet repair device, but the following are the contraindications for the procedures[3][4]:

  • Unable to tolerate anticoagulation
  • Active endocarditis of the mitral valve
  • Rheumatic mitral valve disease 
  • Intracardiac, inferior vena cava (IVC) or femoral venous thrombus

Equipment

The edge-to-edge leaflet repair device procedure is a relatively straightforward procedure requiring only a few specific pieces of equipment listed below:

  • Edge-to-edge leaflet repair device device
  • Multiple catheter sizes
  • Fluoroscopy machine
  • Code cart 
  • Sterile gown
  • Sterile drape
  • Anesthetic

Personnel

The key personnel required to adequately and safely perform catheter-based MR treatment with the edge-to-edge leaflet repair device:

  • Interventional Cardiologist
  • First Assist (sometimes)
  • Cardiology Nurse
  • Surgical Technologist

Preparation

Before undergoing a catheter-based approach to MR management requires a particular assessment of the mitral valve apparatus by echocardiogram and sometimes other forms of cardiac imaging by a trained cardiovascular interventionalist. Sometimes a cardiovascular imaging specialist is used for the consult. The principal preparation for any procedure is to obtain a sterile field. As in most catheterizations, the site of sterilization is the site of catheter insertion. All personnel close to the sterile field should scrub and fully gowned. Clean and drape the area before beginning the procedure.[5] 

Technique

The edge-to-edge leaflet repair device

The transcatheter mitral valve repair with the edge-to-edge leaflet repair device is performed a laboratory specialized for cardiac catheterization. It uses a mix of fluoroscopic and transesophageal echocardiographic (TEE) guidance to image the heart before, during, and after the procedure. The patient is placed under general anesthesia to ease, comfort, and reduce movement during the procedure. The procedure begins with gaining access. The femoral vein is the preferred area of entry. A transseptal puncture is performed to cross the interatrial septum into the left atrium (LA). The edge-to-edge leaflet repair device catheter, which is manipulable within the vasculature, is then advanced into the LA. Echocardiographic guidance instrumentation is used to position the catheter device in the correct place. The edge-to-edge leaflet repair device is then pulled back on with the clip limbs open to attach to the leaflets at the site of insufficiency. The limbs are then closed, and then a repeat Doppler echocardiography is performed to evaluate the results of the treated MR. If the MR has not reduced adequately to the surgeon's satisfaction, then the device can be repositioned [2]. Once the clip positioning is satisfactory, catheter removal from the access site follows and closure ensues with pressure. The patient is then monitored for 4-6 hours post-op to check for any complications.

Complications

The edge-to-edge leaflet repair device has many possible complications to include but not be limited to the following: 

  • Hemorrhage
  • Aneurysm (or pseudo-aneurysm)
  • Arrhythmias 
  • Thromboembolism
  • Mitral stenosis
  • Severe ASD requiring intervention
  • Cardiac perforation
  • Chordal entanglement/rupture
  • Edge-to-edge leaflet repair device thrombosis
  • Renal insufficiency or failure

Clinical Significance

Catheter management of mitral regurgitations is a relatively recent innovation. At the risk of an understatement, it is a considerable advancement in the world of cardiology. It allows for those with severe MR who are nonsurgical candidates to now have an option for mitral valve correction. Recently studies have shown catheter management to be superior to surgical intervention in some circumstances.[1]

Enhancing Healthcare Team Outcomes

Catheter management of mitral valve regurgitation is a serious procedure and can carry some serious potential complications. Fortunately, most complications are rare, but the procedure should be taken seriously and performed by a highly trained cardiovascular interventionalist [level 1]. In addition to a highly trained physician, it is important to have a team approach when assessing these patients. Before the intervention, the following should take place:

  • Explanation of the risks and benefits of catheter management of mitral valve regurgitation as pertains to the specific intervention
  • Evaluation by the pulmonary and cardiologist to optimize lung and heart function
  • Obtain imaging such as an echocardiogram to assess the function and structure of the heart prior to planning the procedure
  • Consult by a cardiovascular imaging specialist or structuralist
  • Pharmaceutical consultation for post-op pain management, antiemetics and use of blood thinners
  • Consult by the anesthesiologist to ensure that the patient is fit for anesthesia
  • Specialty trained cardiology nurse to assist with pre-operative, operative, and post-operative monitoring and education of the patient and coordination of follow-up care with the team.

An interprofessional team approach will lead to the best outcomes. [Level 5]



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References

[1] Mitral Valve Regurgitation in the Contemporary Era: Insights Into Diagnosis, Management, and Future Directions., El Sabbagh A,Reddy YNV,Nishimura RA,, JACC. Cardiovascular imaging, 2018 Apr     [PubMed PMID: 29622181]
[2] Shiota T, Role of echocardiography for catheter-based management of valvular heart disease. Journal of cardiology. 2017 Jan;     [PubMed PMID: 27863908]
[3] Russell EA,Walsh WF,Costello B,McLellan AJA,Brown A,Reid CM,Tran L,Maguire GP, Medical Management of Rheumatic Heart Disease: A Systematic Review of the Evidence. Cardiology in review. 2018 Jul/Aug;     [PubMed PMID: 29608495]
[4] Van Praet KM,Stamm C,Sündermann SH,Meyer A,Unbehaun A,Montagner M,Nazari Shafti TZ,Jacobs S,Falk V,Kempfert J, Minimally Invasive Surgical Mitral Valve Repair: State of the Art Review. Interventional cardiology (London, England). 2018 Jan;     [PubMed PMID: 29593831]
[5] Huang EY,Chen C,Abdullah F,Aspelund G,Barnhart DC,Calkins CM,Cowles RA,Downard CD,Goldin AB,Lee SL,St Peter SD,Arca MJ, Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. Journal of pediatric surgery. 2011 Oct;     [PubMed PMID: 22008341]