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From Mitral Repair to Replacement

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Presentation on theme: "From Mitral Repair to Replacement"— Presentation transcript:

1 From Mitral Repair to Replacement
Mayra Guerrero, MD, FACC, FSCAI Director of Cardiac Structural Interventions NorthShore University HealthSystem CRT 2017 Washington, DC Feb 19, 2017

2 Disclosure Statement of Financial Interest
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Research Grant Support, Proctor Consultant Speaker’s Bureau Edwards Lifesciences Tendyne Holdings/Abbott Abiomed Off label use of products and investigational devices will be discussed in this presentation

3 First Transcatheter Valvular Interventions
Pulmonic Valve Valvotomy Tricuspic Valve Valvotomy Rubio-Alvarez V, Limon-Lason R, Soni, J. Arch Inst Cardiol Mex 1953 April;23(2): Rubio-Alvarez V, Limon-Lason R. Arch Inst Cardiol Mex 1955 Jan-Feb;25(1):57-69.

4 Evolution of Transcatheter Interventions Balloon Valvuloplasty
Coronary Angioplasty 80’s Balloon Valvuloplasty 90’s Coronary Stents 2000’s Valve Replacement

5 Mitral Stenosis Timeline
First TMVR in MAC 2013 1920 1st succesful Surgical Mitral Commissurotomy 1982 Inoue Percutaneous Transvenous MV Commissurotomy (PTMC) Transatrial and Transventricular Closed MV commissurotomy 1902 Concept of mitral commisurotomy proposed Brunton 1994 PMBV Clinically approved in US

6 Percutaneous Transluminal Mitral Commissurotoomy

7

8 NHLBI PMBV Registry n=738 NHLBI Registry participants. Circulation 1992;85:

9 Indirect Annuloplasty Monarch Edwards PMTA Viacor Arto-MVRx
Mechanism Abandoned Approved In Development Leaflet Repair Mobius Edwards Cardica MitraFlex Indirect Annuloplasty Monarch Edwards PMTA Viacor Arto-MVRx Direct Annuloplasty ReCor (US) Cerclage Millipede MitraSpan TASRA Micardia Encor Mitral Bridge QuantumCor (RF) Chordal Repair NeoChord Harpoon Valtech Vchordal MISTRAL Mitralis Enhanced Coaptation Myocor Coapsys MitraSpacer Middle Peak MitrAssisst LV Remodeling Acorn Myocor Accucinch BACE Mardil

10 5-year Results of EVEREST II
Primary MR Survival 30 Day mortality 6% Feldman et al, JACC 2015;66:

11 High Surgical Risk Patients
5-year Results of EVEREST II Primary MR Survival Feldman et al, JACC 2015;66:

12 Outcomes of Approved Devices
Reduction of MR (no elimination) Improvement of Symptoms 5-year survival similar to surgery (MitraClip) Low 30-Day Mortality 7.7% EVEREST II 5.8% STS database 1.9% TITAN 7.8% CE study 5% CE study What else do they have in common ?

13 Operator’s experience ?
Early Outcomes of Transcather MV Replacement Better MR Reduction (almost eliminates MR) But High 30-Day Mortality Patient Selection ? Valve Design ? Operator’s experience ? Access route ? All of the above ?

14 Tendyne Feasibility Trial 30 high risk surgical patients
Muller et al, J Am Coll Cardiol Dec 2016;S (16)

15 Dvir CRT 2017

16 Dvir CRT 2017

17 Mitral Implantation of TRAnscatheter vaLves
The MITRAL Trial Mitral Implantation of TRAnscatheter vaLves Inclusion Criteria Native MV (MAC) Valve-in-Ring Valve-in-Valve Calcific MS (MVA ≤1.5 cm2) Severe MR + Mod MS NYHA II or greater Not surgical candidate Failing surgical ring Severe MR or MS NYHA II or greater Not surgical candidate Failing Bioprosthesis Severe MR or MS NYHA II or greater Not surgical candidate “Goal 100% Transeptal access”

18 Is not what you say… it’s how you say it !

19 Is not what we do to the MV…
it’s how we do it ! What if you could obtain TMV replacement results with the same safety of TMV Repair? “Transeptal Transcatheter MV Replacement” Is this what we need ?

20 Operator Requirements for a Smooth Transition
TAVR experience would help, team approach concept Percutaneous mitral commissurotomy/BMV experience MitraClip experience Transcatheter Mitral Valve-in-Valve experience Transcatheter Mitral Valve-in-Ring experience

21 Institutional Requirements for a Smooth Transition
Heart team approach Excellent quality cardiac imaging expert TAVR experience Percutaneous mitral commissurotomy/BMV experience MitraClip experience Mitral Valve-in-Valve and Valve-in Ring experience

22 Conclusions Repair to Replacement is a natural transition
This transition will take time Operators and Institutions with transcatheter mitral repair experience will have advantage We must resist temptation to perform procedures outside clinical trials Enrollment in clinical trials will be crucial for this field to mature

23 Thank You

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