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Mitral regurgitation (MR) is a prevalent valvular abnormality, often requiring medical management or invasive surgery for severe cases. However, recent studies highlight the increased utilization of a minimally invasive transcatheter approach, particularly the edge-to-edge leaflet repair device. This catheter-based therapy employs a clip to combine the mitral valve leaflets, effectively reducing regurgitation. The activity explores primary and secondary MR, providing insights into noninvasive catheter management options, indications, contraindications, procedural techniques, and potential complications. Emphasizing the role of interprofessional teams in patient care, the activity offers a comprehensive understanding of catheter-based therapies for MR. Clinicians engaging in this activity gain in-depth knowledge of primary and secondary MR, its categorization, and appropriate treatment choices based on disease duration and severity. The activity explores the nuances of echocardiography, emphasizing the significance of transthoracic and transesophageal imaging modalities in evaluating mitral valve morphology and pathology. Specifically, focusing on the edge-to-edge leaflet repair device gives clinicians a nuanced understanding of minimally invasive, catheter-based approaches. Clinicians enhance their expertise in managing MR by comprehensively exploring indications, procedural techniques, and complications associated with noninvasive catheter interventions. Emphasis is placed on interprofessional collaboration, as it provides a holistic understanding of catheter-based therapies for MR, including indications and contraindications. Objectives: Differentiate between primary and secondary mitral regurgitation, recognizing the underlying etiology and determining the optimal management strategy for each type, considering factors such as left ventricular function, left ventricular size, and atrial fibrillation. Identify appropriate candidates for catheter management of mitral regurgitation based on a thorough assessment of valve morphology, pathology, and mechanism using transthoracic echocardiography and, when necessary, transesophageal echocardiography or cardiac magnetic resonance imaging.

Differentiate between primary and secondary mitral regurgitation, recognizing the underlying etiology and determining the optimal management strategy for each type, considering factors such as left ventricular function, left ventricular size, and atrial fibrillation. Identify appropriate candidates for catheter management of mitral regurgitation based on a thorough assessment of valve morphology, pathology, and mechanism using transthoracic echocardiography and, when necessary, transesophageal echocardiography or cardiac magnetic resonance imaging. Communicate effectively with patients, explaining the risks and benefits of catheter management of mitral regurgitation, ensuring informed consent, and addressing any concerns or questions regarding the procedure. Collaborate with an interprofessional team, including cardiologists, imaging specialists, anesthesiologists, and nurses, to optimize patient care throughout the entire process, from preoperative evaluation to postprocedural monitoring. Access free multiple choice questions on this topic.

Mitral regurgitation (MR) is one of the most common valvular abnormalities, second only to aortic valve stenosis.[1][2] Treatment depends on the duration and severity of this condition. Acute severe MR, often caused by papillary muscle rupture or leaflet perforation from infective endocarditis, leads to significant hemodynamic instability, acute volume overload, and congestion—necessitating immediate surgical intervention.[3] Chronic MR can be categorized into 2 types: primary and secondary. Primary MR is caused by a primary abnormality of 1 or more components of the valve apparatus (leaflets, chordae tendineae, papillary muscles, annulus). In contrast, secondary MR is caused by alterations in left ventricular or left atrial function and shape. If mild and asymptomatic, chronic MR can be medically managed and monitored over time. However, patients with symptomatic chronic MR should undergo evaluation for potential surgical intervention.[3][4] In cases of patients who are asymptomatic with chronic MR, surgical consideration may be warranted if they exhibit signs of depressed left ventricular function and dilatation, atrial fibrillation, or pulmonary hypertension.[5][6] Transthoracic echocardiography (TTE) is the initial imaging modality for screening and evaluating mitral valve morphology and pathology and determining the mechanism of MR. TTE also helps quantify the severity of MR and assess left ventricular function and size, and left atrial size.[3] Various parameters are used for qualitative and quantitative MR assessment, including a 2-dimensional analysis of mitral valve leaflet characteristics, motion, coaptation, MR jet to left atrial area ratio, vena contracta, effective regurgitant orifice area, regurgitant volume, regurgitant area, left ventricular ejection fraction, and left ventricular end-diastolic area. In cases where TTE images do not provide adequate information, transesophageal echocardiography (TEE) can offer a more detailed assessment.[7][8] Three-dimensional TEE can provide an "enface" view of the MV, resembling a surgical inspection, which can greatly aid discussions and preprocedure planning (see Image. Mitral Valve, En Face View). In situations where TEE is contraindicated, cardiac magnetic resonance imaging is an alternative option, providing highly accurate data for MR assessment and evaluation of left ventricle dimensions.

In cases where TTE images do not provide adequate information, transesophageal echocardiography (TEE) can offer a more detailed assessment.[7][8] Three-dimensional TEE can provide an "enface" view of the MV, resembling a surgical inspection, which can greatly aid discussions and preprocedure planning (see Image. Mitral Valve, En Face View). In situations where TEE is contraindicated, cardiac magnetic resonance imaging is an alternative option, providing highly accurate data for MR assessment and evaluation of left ventricle dimensions. Results from recent studies have shown percutaneous mitral valve repair as a viable alternative for high-surgical-risk patients suffering from severe symptomatic MR. This procedure has demonstrated low morbidity and mortality rates among many patients.[9] The Endovascular Valve Edge-to-Edge Repair Study Trial (EVEREST) 1 laid the groundwork, demonstrating the safety and feasibility of the edge-to-edge repair technique. The subsequent EVEREST 2 randomized control trial compared percutaneous edge-to-edge repair with surgical mitral valve repair/replacement; this suggested the surgical approach's superiority in reducing MR but also supported the long-term safety of the edge-to-edge repair device and its durability in reducing MR.[10][11] The edge-to-edge leaflet repair device is a minimally invasive, catheter-based therapy based on the principle of the "Alfieri stitch," a surgical technique pioneered by Dr. Ottavio Alfieri, an Italian cardiothoracic surgeon. This technique involves bringing together the 2 flailing leaflets of the MV, resulting in reduced or eliminated regurgitation. Typically, this repair creates a double orifice based on the surgical edge-to-edge Alfieri repair.[12][13] Many percutaneous options exist for patients with MR and multiple comorbidities, placing them at higher risk for surgical interventions.[14] These percutaneous techniques can be classified based on the specific site of the mitral apparatus they target, such as the leaflets (edge-to-edge repair), annulus (indirect or direct annuloplasty), chordae (neo-chords, percutaneous chord implantation), or left ventricle (percutaneous left ventricle remodeling).[14][15][16]

Many percutaneous options exist for patients with MR and multiple comorbidities, placing them at higher risk for surgical interventions.[14] These percutaneous techniques can be classified based on the specific site of the mitral apparatus they target, such as the leaflets (edge-to-edge repair), annulus (indirect or direct annuloplasty), chordae (neo-chords, percutaneous chord implantation), or left ventricle (percutaneous left ventricle remodeling).[14][15][16] This article discusses primary and secondary MR and noninvasive catheter management options, including their indications, contraindications, procedural techniques, and complications. The primary focus of the discussion will be on the United States Food and Drug Administration's approved edge-to-edge repair devices.

Despite the significant comorbidities among the patients being treated, TEER is a safe operation with a low likelihood of major consequences. The table below summarizes the most common complications and their relative occurrence rates (see Table 8. TEER Complications). Table Table 8 TEER Complications. The heightened leaflet perforation, tear, or single leaflet device attachment risk in patients with long-standing secondary MR and calcified leaflets raises significant concerns. The percutaneous retrieval of embolized devices can pose challenges, particularly when larger clips are involved.[70] While afterload mismatch may occur in individuals with reduced left ventricle function, it is an infrequent and transient event typically managed with inotropic medications, often not necessitating mechanical support. Despite its rarity, afterload mismatch may adversely impact long-term outcomes, possibly indicating an advanced stage of heart failure. In some cases of secondary MR with severely impaired left ventricle function, thrombus development in the left atrium or ventricle may occur. Early and intensive anticoagulant therapy may be deemed necessary for these patients.[71] The multidisciplinary team must reassess the indication for mitral valve surgery or reintervention when confronted with residual or recurrent MR. A repeat transesophageal echocardiography is typically warranted to comprehend the underlying disease, identify residual leaflet anatomy for potential device implantation, and assess the risk of significant mitral stenosis. In case series with limited safety data, alternative interventional strategies for managing substantial para-clip or inter-clip residual MR have been explored. Examples include using an Amplatzer vascular plug (Abbott), originally designed for peripheral vasculature embolization, or an enlarged polytetrafluoroethylene double-disk occluder, initially intended for closing atrial septal defects.[38][72] According to a large multicenter registry, implant failure due to leaflet perforation, tear, or loss affects 3.5% of patients and is associated with increased in-hospital and long-term mortality.[73] Redo TEER is a viable option and may be preferable to surgery in anatomically suitable patients with primary or secondary MR, especially when surgical outcomes are suboptimal.[74]

Catheter management of mitral valve regurgitation demands a comprehensive approach from an interprofessional team to ensure patient-centered care, optimize outcomes, enhance patient safety, and improve team performance. Physicians, advanced practitioners, nurses, pharmacists, and other health professionals play pivotal roles in various aspects of this procedure. Physicians, particularly highly trained cardiovascular interventionalists, lead the procedural aspects. They collaborate with advanced practitioners to ensure thorough patient assessments and communicate risks and benefits effectively. Nurses specializing in cardiology are essential for preoperative, operative, and postoperative monitoring, patient education, and coordination of follow-up care. Interprofessional communication is facilitated by cardiovascular imaging specialists, structuralists, and anesthesiologists who contribute their expertise in optimizing lung and heart function, providing specialized imaging, and ensuring the patient's readiness for anesthesia. Pharmacists are crucial for pharmaceutical consultation, addressing postoperative pain management, antiemetics, and blood thinners. This multidisciplinary approach, driven by effective communication and care coordination, is vital for a successful catheter management procedure. Emphasizing this interprofessional collaboration enhances patient safety, improves outcomes, and contributes to overall team performance in the complex landscape of mitral valve regurgitation interventions.