Dr. Franz Weidinger,
Mitral regurgitation (MR) is a frequent valvular condition that increases with age and causes progressive left ventricular dysfunction associated with significant morbidity and mortality. Studies have shown that only about half of the patients with severe symptomatic MR receive operation, either mitral valve repair or valve replacement. In this session, new surgical and percutaneous approaches were discussed.
Dr. De Bonis from Milan showed several new techniques of mitral annuloplasty, mainly flexible rings that can be adjusted according to the required size of the annulus to achieve valve competence in case of malcoaptation. The success of the intervention is checked off-pump with echocardiography. Other promising techniques used by the group of Prof. Alfieri include adjustable artificial chordae either by the conventional open surgical approach or via the transapical route.
The percutaneous edge to edge technique using the MitraClip device was described by Dr. Franzen from Copenhagen, DK. Altogether 3,000 patients have been treated with this new technique that is able to reduce the amount of regurgitation, leading to a reduction in left ventricular volumes and to an improvement in NYHA functional class. This device has received CE mark in April 2011 following the publication of the first RCT EVEREST II, leading to a steep increase in its application in Europe. EVEREST II included 279 patients, randomized in a 2:1 ratio between surgery (repair or replacement) and percutaneous repair, showing a lower efficacy of the latter, defined as death, need for surgery, or grade 3+ or 4+ regurgitation at 12 months.
However, fewer adverse events occurred at 30 days in the percutaneous compared to the surgical group. Percutaneous coronary sinus annuloplasty was reviewed by Dr. Harnek from Lund, SE. Several devices have been tested, but 2 of 3 had to be withdrawn because of selective/ too slow enrolment in studies. Other shortcomings of this approach include the hazard of compression of the circumflex coronary artery by the device. More results are needed.
Prof. Alec Vahanian gave the “bird’ s eye view” by emphasizing the complexity of MR and the frequent high comorbidity in affected patients. “Valves are repairable but patients are not”, he quoted a surgical colleague. He commented on the EVEREST II trial in saying that the improvement which was still substantial after 2 years (80%) may be acceptable for this high risk population including elderly patients with poor LV function.
However, he concluded by saying that improvement is necessary for this percutaneous approach, selection of patients is crucial, with careful guidance by imaging techniques. There are considerable unmet needs in the large population with non-organic MR, which may require the combination of techniques as well as careful evaluation of results in comparison with surgery and contemporary medical therapy.
New therapies for mitral regurgitation
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