Percutaneous Mitral Valve Repair
Percutaneous mitral valve repair (MVR) is used to treat mitral regurgitation (MR; depicted in the image below). Percutaneous procedures used to treat valvular heart disease were first developed decades ago; the first pulmonic balloon valvuloplasty was reported in 1982 and was quickly followed by applications to the aortic and mitral valves. [1, 2] Mitral stenosis was the first pathologic condition of a heart valve to be treated both surgically  and percutaneously. 
Over the past 20 years, percutaneous mitral balloon valvuloplasty used to treat mitral stenosis has yielded excellent success rates in patients with suitable valvular and subvalvular morphology.  However, clinically viable percutaneous treatments for mitral regurgitation have become available only recently.
Newer approaches have progressed far beyond balloon valvuloplasty to include catheter techniques for emulating surgical annuloplasty and edge-to-edge repair of regurgitant mitral valves. These are still in early-stage clinical (or preclinical) testing, and the ultimate degree of clinical success and adoption is still unclear. Given the outstanding results of open valve repair, surgery is likely to remain the criterion standard for most cases of symptomatic valvular heart disease.
A study by Nickenig et al of transcatheter MVR in Europe found that such treatment had a high acute procedural success rate (95.4%) and that reduction in the severity of mitral regurgitation persisted at 1 year. The multinational study, which involved 628 patients, also determined that the acute procedural success rate was similar between patients with functional mitral regurgitation and those with degenerative mitral regurgitation, as were the inhospital and estimated 1-year mortality rates (2.9% and 15.3%, respectively). However, the patients with functional mitral regurgitation had a significantly higher estimated 1-year rate of heart failure-related rehospitalization than did the other group (25.8% versus 12.0%, respectively). 
In the near term, percutaneous valve intervention will probably have two indications, as follows:
Severe disease deemed inoperable owing to comorbid disease
Early-stage regurgitant lesions if less-invasive valve repair may prevent progressive ventricular enlargement
Although definitive catheter-based therapies for valvular heart disease are clearly in their infancy, various percutaneous approaches are now being evaluated and used. The field is likely to develop rapidly over the next several years, with refinement of the above approaches and emergence of still newer technologies.
The landscape of clinical trials is also still under active discussion; if these percutaneous techniques are to be considered as alternatives to traditional surgical methodologies in low-risk to medium-risk patients, they must demonstrate hemodynamic effects, safety, and durability comparable to those of the current highly refined surgical techniques. Conversely, these percutaneous techniques may be best applied to patients at the margins of current surgical indications.
The human heart has 4 valves. The left atrium (LA) is connected to the left ventricle (LV) via the mitral valve, which opens during diastole to allow blood to flow from the LA to the LV. During ventricular systole, the mitral valve closes and prevents backflow to the LA. The normal function of the mitral valve depends on its 6 components, which include the left atrial wall, the annulus, the leaflets, the chordae tendineae, the papillary muscles, and the left ventricular wall.
Despite the general enthusiasm generated by these emerging devices, establishing which patient populations are suitable for such technologies is important. The two causes of mitral regurgitation most amenable to surgical repair include degenerative and functional etiologies.
Annuloplasty is the main technique for treating functional mitral regurgitation, whereas leaflet repair is also usually performed to treat degenerative mitral regurgitation.
Therefore, the percutaneous options currently available may be useful only in selected patients. The excellent results and low perioperative mortality associated with surgical repair further emphasize the need for a cautious approach to percutaneous MVR.
Kan JS, White RI Jr, Mitchell SE, Gardner TJ. Percutaneous balloon valvuloplasty: a new method for treating congenital pulmonary-valve stenosis. N Engl J Med. 1982 Aug 26. 307(9):540-2. [Medline].
Cribier A, Savin T, Saoudi N, Rocha P, Berland J, Letac B. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement?. Lancet. 1986 Jan 11. 1(8472):63-7. [Medline].
Mao S, Shinbane JS, Girsky MJ, et al. Coronary venous imaging with electron beam computed tomographic angiography: three-dimensional mapping and relationship with coronary arteries. Am Heart J. 2005 Aug. 150(2):315-22. [Medline].
Gerber TC, Sheedy PF, Bell MR, et al. Evaluation of the coronary venous system using electron beam computed tomography. Int J Cardiovasc Imaging. 2001 Feb. 17(1):65-75. [Medline].
Maselli D, Guarracino F, Chiaramonti F, et al. Percutaneous mitral annuloplasty: an anatomic study of human coronary sinus and its relation with mitral valve annulus and coronary arteries. Circulation. 2006 Aug 1. 114(5):377-80. [Medline].
Nickenig G, Estevez-Loureiro R, Franzen O, et al. Percutaneous mitral valve edge-to-edge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011-2012 Pilot European Sentinel Registry. J Am Coll Cardiol. 2014 Sep 2. 64(9):875-84. [Medline].
Fedak PW, McCarthy PM, Bonow RO. Evolving concepts and technologies in mitral valve repair. Circulation. 2008 Feb 19. 117(7):963-74. [Medline].
Cubeddu RJ, Palacios IF. Percutaneous techniques for mitral valve disease. Cardiol Clin. 2010 Feb. 28(1):139-53. [Medline].
Piazza N, Asgar A, Ibrahim R, Bonan R. Transcatheter mitral and pulmonary valve therapy. J Am Coll Cardiol. 2009 May 19. 53(20):1837-51. [Medline].
Masson JB, Webb JG. Percutaneous treatment of mitral regurgitation. Circ Cardiovasc Interv. 2009 Apr. 2(2):140-6. [Medline].
Feldman T. Percutaneous mitral valve repair. J Interv Cardiol. 2007 Dec. 20(6):488-94. [Medline].
Block PC. Percutaneous transcatheter repair for mitral regurgitation. J Interv Cardiol. 2006 Dec. 19(6):547-51. [Medline].
Alfieri O, Maisano F, De Bonis M, et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg. 2001 Oct. 122(4):674-81. [Medline].
Webb JG, Maisano F, Vahanian A, Munt B, Naqvi TZ, Bonan R. Percutaneous suture edge-to-edge repair of the mitral valve. EuroIntervention. 2009 May. 5(1):86-9. [Medline].
Maisano F, Caldarola A, Blasio A, De Bonis M, La Canna G, Alfieri O. Midterm results of edge-to-edge mitral valve repair without annuloplasty. J Thorac Cardiovasc Surg. 2003 Dec. 126(6):1987-97. [Medline].
Bhudia SK, McCarthy PM, Smedira NG, Lam BK, Rajeswaran J, Blackstone EH. Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings. Ann Thorac Surg. 2004 May. 77(5):1598-606. [Medline].
Williams JL, Toyoda Y, Ota T, Gutkin D, Katz W, Zenati M. Feasibility of myxomatous mitral valve repair using direct leaflet and chordal radiofrequency ablation. J Interv Cardiol. 2008 Dec. 21(6):547-54. [Medline].
Goel R, Witzel T, Dickens D, Takeda PA, Heuser RR. The QuantumCor device for treating mitral regurgitation: an animal study. Catheter Cardiovasc Interv. 2009 Jul 1. 74(1):43-8. [Medline].
Otto CM. Timing of surgery in mitral regurgitation. Heart. 2003 Jan. 89(1):100-5. [Medline].
Timek TA, Lai DT, Tibayan F, Liang D, Daughters GT, Dagum P. Septal-lateral annular cinching abolishes acute ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2002 May. 123(5):881-8. [Medline].
Maselli D, Guarracino F, Chiaramonti F, Mangia F, Borelli G, Minzioni G. Percutaneous mitral annuloplasty: an anatomic study of human coronary sinus and its relation with mitral valve annulus and coronary arteries. Circulation. 2006 Aug 1. 114(5):377-80. [Medline].
Lansac E, Di Centa I, Al Attar N, et al. Percutaneous mitral annuloplasty through the coronary sinus: an anatomic point of view. J Thorac Cardiovasc Surg. 2008 Feb. 135(2):376-81. [Medline].
Choure AJ, Garcia MJ, Hesse B, et al. In vivo analysis of the anatomical relationship of coronary sinus to mitral annulus and left circumflex coronary artery using cardiac multidetector computed tomography: implications for percutaneous coronary sinus mitral annuloplasty. J Am Coll Cardiol. 2006 Nov 21. 48(10):1938-45. [Medline].
Tops LF, Van de Veire NR, Schuijf JD, et al. Noninvasive evaluation of coronary sinus anatomy and its relation to the mitral valve annulus: implications for percutaneous mitral annuloplasty. Circulation. 2007 Mar 20. 115(11):1426-32. [Medline].
Palacios IF, Condado JA, Brandi S, et al. Safety and feasibility of acute percutaneous septal sinus shortening: first-in-human experience. Catheter Cardiovasc Interv. 2007 Mar 1. 69(4):513-8. [Medline].
Sorajja P, Nishimura RA, Thompson J, Zehr K. A novel method of percutaneous mitral valve repair for ischemic mitral regurgitation. JACC Cardiovasc Interv. 2008 Dec. 1(6):663-72. [Medline].
Kim JH, Kocaturk O, Ozturk C, Faranesh AZ, Sonmez M, Sampath S. Mitral cerclage annuloplasty, a novel transcatheter treatment for secondary mitral valve regurgitation: initial results in swine. J Am Coll Cardiol. 2009 Aug 11. 54(7):638-51. [Medline].
Ramin Assadi, MD Assistant Professor of Medicine, Division of Interventional Cardiology, University of California, Los Angeles, David Geffen School of Medicine
Ramin Assadi, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, Society for Cardiovascular Angiography and Interventions
Disclosure: Nothing to disclose.
Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine
Disclosure: Nothing to disclose.
Michael Benz, MD, FACC, FSCAI Chief, Division of Cardiology, Christ Hospital; Voluntary Clinical Assistant Professor, Division of Cardiology, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Physician, Advanced Cardiac Care, LLC
Michael Benz, MD, FACC, FSCAI is a member of the following medical societies: American College of Cardiology, American Medical Association, American Society of Echocardiography, Society for Cardiac Angiography and Interventions, and Society for Vascular Medicine and Biology
Disclosure: Nothing to disclose.
The authors and editors of Medscape Reference gratefully acknowledge the contributions made to this article by the following physicians from Jersey City Medical Center/Mount Sinai School of Medicine: Douglas Ratner, MD, Chairman and Program Director of Medicine; Sujatha Doddi, MD, Resident in Internal Medicine; Anshu Alok, MD, Resident in Internal Medicine; and Manish Sharma, MD, Chief of Internal Medicine.
Percutaneous Mitral Valve Repair
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