Transcatheter mitral valve intervention

Last revised by Joachim Feger on 11 Nov 2021

Transcatheter mitral valve interventions (TMVI) or percutaneous mitral valve interventions are less-invasive, highly technical procedures available for the management of selected patients with mitral valve regurgitation and include several transcatheter mitral valve repair (TMVr) and transcatheter mitral valve replacement (TMVR) techniques 1-6:

  • transcatheter edge-to-edge repair (TEER)
  • indirect mitral annuloplasty
  • direct mitral annuloplasty
  • chordae tendineae repair or replacement
  • left ventricular repair
  • transcatheter mitral valve replacement
  • transcatheter mitral valve-in-valve or valve-in ring procedure

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The first transcatheter edge-to-edge repair has been performed in 2003 and has been approved in Europe in 2008 and in the US in 2013 with the last upgrade getting approval in 2019 6-8.

Transcatheter mitral annuloplasty devices have been approved in Europe since 2011, the first technique was an indirect mitral annuloplasty. Direct annuloplasty techniques gained approval in Europe in 2015 7. 

Chordae tendineae replacement gained approval in Europe in 2013. 

The first transcatheter mitral valve replacement system has been implanted in 2012 and approved for use in Europe in 2020. Transcatheter mitral valve-in-valve and valve-in ring options are approved in Europe and the US since recently.

Up till now, the only guideline-supported transcatheter mitral valve intervention is the transcatheter mitral valve edge-to-edge leaflet repair and according to the 2020 ACC/AHA and 2021 ESC/EACTS Guidelines for the Management of Valvular Heart disease, this is considered reasonable in severe primary and secondary mitral valve regurgitation in symptomatic patients, who are considered inoperable, or as high surgical risk by a multidisciplinary heart team 6,9,10.

The other devices are under early clinical evaluation and/or development in particular most of the transcatheter mitral valve replacement devices 1,6.

Indirect and direct mitral annuloplasty techniques are indicated in functional mitral regurgitation secondary to ischemic or non-ischemic left ventricular dilation 11,12. Chord replacement is an option for mitral prolapse especially if the posterior leaflet and only one segment are involved 7,13.

Transcatheter mitral valve interventions require patient evaluation by a multidisciplinary heart team and should be undertaken in a comprehensive heart valve center 6.

Contraindications of transcatheter mitral valve interventions include 9,10:

  • unfavorable characteristics for transcatheter mitral valve intervention
  • patients with severe mitral regurgitation who are suitable for mitral valve surgery
  • futility or short life expectancy <1 year

In addition, there are procedure-related contraindications against individual techniques concerning mitral annular and leaflet anatomy, proximity to the left circumflex artery and the access route.

The procedure requires a collaborative multidisciplinary team of general and interventional cardiologists, cardiac valve surgeons, cardiac anesthesiologists, heart failure specialists and imaging experts with appropriate expertise on the subject including valvular heart disease, heart failure, electrophysiology and advanced cardiac imaging 6,9,10.

The procedure will vary with the technique and the device. It will be conducted under fluoroscopic and transesophageal echocardiographic guidance and includes the following steps 1:

  • establishing access via device-specific access route
  • advancement of the device
  • centering and alignment of the device
  • device deployment

Choice of technique and device selection will depend on the exact underlying etiology including primary/secondary mitral regurgitation, mitral annular dilation, mitral valve prolapse/flail leaflet as well as the available access route and the experience and preference of the heart team.

Transcatheter mitral valve repair devices can be categorized with regard to the target region such as mitral valve leaflets, mitral annulus, chordae tendineae and the left ventricle 1-5.

Transcatheter edge-to-edge repair involves clipping of the anterior and posterior leaflets and creation of a double orifice mitral valve in analogy to the Alfieri method 3,4 using a transcatheter guided procedure over transfemoral venous access and a transeptal puncture.

Techniques aim at reducing mitral annular dilation with different anchoring or cerclage systems that utilize the coronary sinus to apply a constraint to the mitral annulus. They constitute more simple methods than direct annuloplasty to improve leaflet coaptation 3,11. The access route is transvenous with or without transeptal puncture 11.

Direct annuloplasty achieves a mitral annular diameter reduction employing direct mitral annular fastening with anchors or pledgets and allows a close approximation to the mitral valve 11,12. Depending on the device access route is transvenous, transarterial or transaortic.

Chordal repair and/or replacement techniques involve either the attachment of artificial chords to prolapsed or flail leaflets to the left ventricle under transesophageal echocardiographic guidance with a transapical approach or the transeptal application of a device that pulls the chords together 3,4,13.

Ventricular repair systems aim to reduce secondary functional mitral regurgitation by device implantation into the left ventricle.

Transcatheter mitral valve replacement involves the replacement of the native mitral valve as a whole. Prosthesis stability is achieved utilizing different anchoring mechanisms including apical tether, native leaflet engagement, mitral annular clamping, annular winglets, radial force or external anchors 5. Most transcatheter mitral valve replacement devices are still under development and require a transapical approach with few devices using transvenous access with transeptal puncture 5,6.

Transcatheter mitral valve-in-valve or valve-in-ring procedures refer to transcatheter implantation of a mitral prosthesis in the setting of failed surgical mitral valve replacement or repair. Devices come with a transapical or transvenous approach.

The access route varies with the technique and the implantable device and includes the following options 1-5:

  • transvenous access
    • via the femoral, internal jugular and subclavian veins
    • with or without transeptal puncture
  • transarterial or transaortic access
  • transapical access

The different access routes feature their advantages and disadvantages, with transvenous and transarterial access being considered less invasive than a transaortic or transapical approach, but the two latter having the advantage of a shorter distance and the transapical approach also a direct route to the mitral valve 5. Most of the transcatheter mitral valve replacements use a transapical approach mostly due to the size of the artificial valve 5.

Complications of transcatheter mitral valve interventions are dependent on technique, the device and the access.

Peri-procedural or short term complications include 3,14,15:

Long term and post-procedural complications include 14,15:

Pre-procedural imaging includes a qualitative and quantitative assessment of mitral regurgitation to assure the indication of the procedure and to determine the underlying etiology (degenerative or functional) 16.

In addition, it serves planning the procedure and subject to the eligible technique it will include not only transthoracic and transesophageal echocardiography but also cardiac CT 5,16-20.

Transthoracic echocardiography serves the initial evaluation of mitral regurgitation including the etiology and the assessment of left atrial and left ventricular and size and function 16. Patient selection and is usually then done with 2D and 3D transesophageal echocardiography including the assessment of the following parameters 16:

  • mitral valve area and gradients
  • mitral leaflet and annular calcifications
  • location of the pathology
  • mitral leaflet morphology (thickness, mobility and grasping zone)
  • coaptation depth
  • flail width and flail gap

Cardiac CT shines in the evaluation of mitral annular as well as left ventricular anatomy including papillary muscles and the left ventricular outflow tract. In addition, it can give information regarding the proximity of the circumflex artery to the mitral annulus 7. CT analysis is usually done with dedicated software modules and depending on the planned procedure it will include an assessment of the following 5,16-19:

  • anatomy of the mitral valve and mitral annulus
  • mitral annular dimensions
    • intercommisural, trigone-to-trigone, septal-to-lateral distances
    • projected mitral annular area 2D and 3D perimeter
    • projected distances to the annular plane
    • mitral annular axis (trajectory)
    • en-face view and compromise view angulations
  • mitral leaflet morphology
  • mitral leaflet and annular calcifications
  • chordae tendineae and papillary muscle anatomy
    • distance between the heads of the papillary muscles
    • projected distances to the mitral annulus center and plane
    • distance to the left ventricular wall
  • left ventricular outflow tract anatomy including dimensions and aortomitral angulation
  • valve simulation and neo-left ventricular outflow tract quantification

Periprocedural imaging is mainly done with transesophageal echocardiography and fluoroscopy and involves imaging guidance for the following steps 19:

  • localization of access and ventricular or transseptal puncture
  • advancement and positioning of the guidewire
  • advancement and positioning of the delivery system
  • device deployment
  • device alignment 
  • device anchoring
Post-procedural imaging

Imaging after transcatheter mitral valve interventions aims at the evaluation of valvular competence and potential complications. It involves the assessment of the following 19:

  • valvular competence and transmitral gradients
  • left ventricular outflow tract anatomy and gradients
  • device position, fitting and stability
  • leaflet mobility
  • potential complications
    • paravalvular leak
    • leaflet thrombosis
    • device detachment

According to the AHA/ACC transthoracic echocardiography is the recommended baseline imaging modality for postprocedural imaging and periodic monitoring 10.

Transesophageal echocardiography and cardiac CT have slight advantages in the evaluation of left ventricular outflow tract anatomy, device position and complications as leaflet thrombosis.

The radiological report of a pre interventional evaluation will depend on the planned procedure and should include a description of the following 5,16,19:

  • presence, degree and quantification of mitral regurgitation
  • mitral annular anatomy including shape and dimensions
  • mitral leaflet morphology including dimensions
  • mitral annular and leaflet calcifications
  • chordae tendineae
  • papillary muscle anatomy (distance between heads and to the mitral annular plane)
  • left ventricular and left atrial volumes, dimensions and function
  • left ventricular outflow tract anatomy
  • access anatomy
  • position of the left ventricular apex (distance from sternal midline, intercostal space)
  • iliofemoral venous anatomy
Post-procedural evaluation

In a postinterventional setting the radiological report should include a description of the following 19:

  • device position, fitting and stability
  • leaflet mobility
  • mitral valvular competence including trans-mitral gradient
  • left ventricular outflow tract anatomy and gradients
  • possible complications
    • leaflet thrombosis
    • paravalvular leak
    • device detachment
    • stent fracture

Outcomes vary with the procedure and the device 7. Transcatheter edge-to-edge repair with MitraClip features a superior short term safety profile compared to surgical treatment with no difference after five years 21. However, so far surgical repair or reconstruction proved to be more effective in reducing mitral regurgitation after 5 years 22. Many of the more recently approved devices show promising results at short-term follow-up but require further evaluation with clinical trials 7. Chord replacement showed best results with single-segment posterior leaflet prolapse 7.

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