Track 7: Transcatheter Mitral Valve Repair

Question 1

Mitral regurgitation, what are the main options as disease progresses?

Answer 1

Refer for mitral valve surgery
Refer for MitraClip (Abbot mitraclip actually recalled d/t malfunctioning while locked
Increase Lasix (diuretic)
Sequentially add Metoprolol (BB) and Lisinopril (ACE or ARB)

Question 2

Mitral regurgitation classification

Answer 2

Question 3

2 broad categories of mitral regurgitation

Answer 3

Primary (degenerative) MR
Secondary (functional) MR

Question 4

Primary (degenerative) MR is often due to

Answer 4

Prolapse
Flail
Rheumatic valve disease
Mitral annular calcification

Question 5

Secondary (functional) MR is often due to

Answer 5

Atrial enlargement
Nonischemic CMP, LV myocardium is diseased/enlarged pulling the valve together
Ischemic CMP (regional wall motion abnormality disrupts valve apparatus, leads to eccentric or “non-central” MR)

(tethering of the mitral valve)

Question 6

COAPT

Answer 6

Randomized patients with secondary MR
Don’t have primary leaflet issue
Less hospitalizations for heart failure in mitral clip group
*Must be on max tolerated doses of GDMT and CRT-D if indicated

***Note another study french MITRA-FR study came out at same time and showed no benefit with mitraclip

Question 7

MITRA-FR vs COAPT

Answer 7

COAPT
- slightly larger and took patients that were less sick
- EF had to be > 20%
- LVESD ≤ 70 mmHg
- mod-Severe MR but more on the severe (regurg >45)

MITRA-FR
- Smaller, sicker
- EF 15-40%
- No LVESD criteria
- Less strict on severe MR
- Regurg volume >30 permitted, so some mild-mod included

*** likely discordance due to proportional vs disproportional secondary MR. Ie how much is the MR contributing to the study. Possible/likely that in MITRA-FR there were too many patients with severe and proportional MR
Ie patient with hugely dilated LV and severe MR, fixing mitral still leaves huge LV, likely wont help. much
Patient with relatively well functioning LV and severe MR, if you fix the MR they will do better

Question 8

Anatomical suitability for MitraClip

Answer 8

Best anatomy for mitraclip is if the regurgitation is central (ie between A2 and P2)
On the sides there are chords that may impede ability to place clip in correct location

Better outcome if flail cap < 10 mm and flail width < 15 mm

Annular Ca++ is a limiting factor

Posterior leaflet cleft not ammenable

Question 9

What are 2 ways to measure success of mitraclip intraoperatively

Answer 9

Color flow doppler to evaluate residual regurgitation

Left atrial pressure measurements, with successful clip, should see overall decrease in left atrial pressure (less regurgitation into LA)

Question 10

Infective endocarditis abx prophylaxis

Answer 10

2020 guidelines
1. (2a) Abx prophylaxis reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of periapical region of teeth, or perforation of the oral mucosa in patients with VHD or the following:
- Prosthetic cardiac valve
- Prosthetic material used for valve repair
- Unrepaired cyanotic congential heart disease or repaired congenital heart disease with residual shunts/regurgitation
- Cardiac transplant with valve regurgitation d/t structurally abnormal valve

2. (3) VHD and high risk of IE, abx prophylaxis not recommended for nondental procedures (ie TEE, EGD, colonoscopy, cystoscopy) in the absence of active infection