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Cardiology
Percutaneous Therapies for Mitral Valve Disease Valvuloplasty for Mitral Stenosis and Percut
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
10 sections · 187 slides
Burden of mitral valve disease and mitral anatomy
- Prevalence of mitral regurgitation
- Changing epidemiology of mitral stenosis
- Why transcatheter mitral therapy developed
- Components of the mitral valve complex
- Mitral valve anatomy on echocardiography and computed tomography
- Structure of the mitral annulus
- Carpentier scallop nomenclature
- Types of chordae tendineae
- Papillary muscle supply to leaflet segments
Mitral stenosis: mechanism and assessment
- Etiology of mitral stenosis
- Mechanism of rheumatic valve damage
- Rheumatic mitral stenosis on transesophageal echocardiography
- Rheumatic mitral stenosis by region
- Degenerative mitral stenosis
- Risk associations of mitral annular calcification
- Uncommon causes of mitral stenosis
- Clinical manifestations of mitral stenosis
- Auscultatory findings in mitral stenosis
- Mitral valve area and severity thresholds
- Limitations of the transmitral gradient
- Scoring systems for commissurotomy eligibility
- Reading the Wilkins score
- Wilkins score for assessment of mitral valve anatomy before percutaneous mitral balloon commissurotomy
- Stress testing when symptoms are discordant
- Cardiac catheterization in mitral stenosis
- Role of transesophageal echocardiography before commissurotomy
- Transesophageal echocardiography in commissurotomy planning
- Computed tomography in degenerative mitral stenosis
Percutaneous mitral commissurotomy
- Medical therapy in rheumatic mitral stenosis
- Class I indication for percutaneous mitral commissurotomy
- Commissurotomy in asymptomatic severe rheumatic stenosis
- Guideline divergence above 1.5 cm²
- Contraindications to commissurotomy
- Concomitant disease precluding commissurotomy
- Unfavourable anatomy for commissurotomy
- Development of balloon commissurotomy
- The double-balloon technique
- The Inoue balloon
- Inoue balloon components
- The Inoue balloon set
- Inflation behaviour of the Inoue balloon
- The Accura balloon
- Selecting balloon size
- Intra-procedural measurement of the stenotic mitral valve area
- Access and sedation for commissurotomy
- Transseptal puncture for commissurotomy
- Crossing the mitral valve with the Inoue balloon
- Balloon dilatation and stepwise sizing
- Endpoint of stepwise dilatation
- Balloon commissurotomy under fluoroscopy
- Complications of percutaneous mitral commissurotomy
- Reducing procedural risk
- Declining utilisation and operator proficiency
- Pulmonary vascular disease and timing of intervention
- Percutaneous commissurotomy: summary position
Degenerative mitral stenosis
- Indications for intervention in degenerative stenosis
- Difficulty of valve replacement in annular calcification
- Early transcatheter replacement using aortic valves
- Transcatheter valve therapy registry outcomes
- Outcomes of valve-in-mitral annular calcification
- MITRAL trial results in the calcification arm
- Left ventricular outflow tract obstruction in calcific disease
- Reported incidence of outflow tract obstruction
- Preventive strategies for outflow tract obstruction
- Current status of replacement in degenerative stenosis
- Dedicated devices in mitral annular calcification
- Tendyne and the SUMMIT trial calcification cohort
- Intrepid and Cephea experience
- Ongoing trials with dedicated calcification arms
Mitral regurgitation: mechanism and assessment
- Acute mitral regurgitation
- Carpentier classification of mitral regurgitation
- Mechanisms of mitral regurgitation by leaflet motion
- Type I mitral regurgitation
- Type II mitral regurgitation
- Fibroelastic deficiency and myxomatous disease
- Type III mitral regurgitation
- Primary and secondary disease within the classification
- Haemodynamic consequences of mitral regurgitation
- Symptoms and examination in mitral regurgitation
- Echocardiography in mitral regurgitation
- Three-dimensional imaging of the mitral valve
- Cardiac magnetic resonance and computed tomography
- Quantitative thresholds for severe regurgitation
- Supportive Doppler signs of severe regurgitation
Treatment indications in mitral regurgitation
- Medical therapy for mitral regurgitation
- Surgery in primary mitral regurgitation
- Edge-to-edge repair in primary mitral regurgitation
- Secondary mitral regurgitation and the Heart Team
- Surgery in secondary mitral regurgitation
- COAPT criteria for edge-to-edge repair
- Position of transcatheter replacement in guidelines
The transcatheter menu for mitral regurgitation
- Categories of transcatheter mitral therapy
- Coaptation devices for edge-to-edge repair
- Transcatheter annuloplasty devices
- Chordal replacement and ventricular remodelling devices
Transcatheter edge-to-edge repair
- Origin of edge-to-edge repair
- EVEREST II trial
- Early approvals and registry evidence
- MITRA-FR trial
- COAPT trial
- Why MITRA-FR and COAPT differed
- PASCAL system and the CLASP IID trial
- Edge-to-edge repair in acute mitral regurgitation after infarction
- Edge-to-edge repair in severe left ventricular dysfunction
- Edge-to-edge repair in hypertrophic obstructive cardiomyopathy
- MitraClip system components
- Edge-to-edge repair clip system and clip sizes
- MitraClip clip sizes
- PASCAL system components
- PASCAL delivery system and implants
- PASCAL implant design
- Access and transseptal puncture for edge-to-edge repair
- Optimal transseptal puncture during edge-to-edge repair
- Advancing the device into the left atrium
- Imaging guidance during edge-to-edge repair
- Aligning the device with the coaptation line
- Leaflet grasping during edge-to-edge repair
- Grasping and assessing the result
- Release and additional devices
- Unsuitability for repair: risk of iatrogenic stenosis
- Unsuitability for repair: inadequate regurgitation reduction
- Unsuitability for repair: technical and imaging barriers
- Unsuitability for repair: futility
- Patients outside the COAPT criteria
Transcatheter mitral valve replacement
- Rationale for transcatheter replacement
- CHOICE-MI registry outcomes
- Determinants of survival after replacement
- Design constraints of replacement devices
- Valve frame and prosthetic leaflets
- Why radial force alone cannot anchor a mitral prosthesis
- Anchoring mechanisms of replacement devices
- Sealing mechanisms
- Reading the device table
- Transcatheter mitral valve replacement devices: available valve sizes
- Transcatheter mitral valve replacement devices: anchoring mechanism
- Transcatheter mitral valve replacement devices: access and reported evidence
- Transcatheter mitral valve replacement devices: stated advantages
- Transcatheter mitral valve replacement devices: stated advantages (continued)
- Transcatheter mitral valve replacement devices: stated advantages (continued)
- Transcatheter mitral valve replacement devices: potential disadvantages
- Device shapes that follow from the anchoring problem
- Atrial cage anchoring
- Wide atrial flange with a short ventricular skirt
- Inner valve stent within an outer sealing frame
- Multiple anchors engaging annulus and subvalvular tissue
- Crown-shaped atrial frame over a covered ventricular body
- Broad atrial flange with a tri-leaflet bioprosthesis
- D-shaped outer frame with a sewn sealing cuff
- Valve seated within a separate docking ring
- Apical tether with an epicardial pad
- Left ventricular outflow tract obstruction after replacement
- The neo-LVOT concept
- Limits of neo-LVOT prediction
- LAMPOON leaflet laceration
- SESAME septal scoring
- Septal reduction to enlarge the neo-LVOT
- Screen failure in transcatheter mitral replacement
- Antithrombotic therapy after replacement
Choosing between the options
- Repair compared with replacement
- Patients who remain untreatable
- Key points: mitral stenosis
- Key points: mitral regurgitation
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- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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