A Closer Look at Mitral Valve Regurgitation

Mitral regurgitation is the most common disease of the mitral valve.

The mitral valve is located between the left atrium and ventricle. It opens during systole, when blood enters the left ventricle from the left atrium, and it closes during ventricular contraction, when blood exits the left ventricle to perfuse the rest of the body.

Unlike the aortic valve, a trileaflet structure that passively opens and closes during the cardiac cycle, the mitral valve is a bileaflet structure with a subvalvular apparatus consisting of cords that connect its leaflets to the papillary muscles. Papillary muscles are part of the left ventricle that help keep the mitral valve closed during ventricular contraction (Figure 1).

The Mitral Valve of the Heart

Figure 1 – The Mitral Valve

Mitral regurgitation is the leakage of blood back into the atrium during left ventricular contraction, resulting from inappropriate closure of the valve leaflets in systole. When regurgitation is mild it is well tolerated and no therapy is needed. However, patients can become symptomatic as the severity of the leakage increases.

Symptoms occur because the increased volume in the left atrium ultimately results in increased pressure in this chamber. This increase in pressure can cause congestion of the lungs resulting in shortness of breath, decrease in exercise tolerance and lower extremity swelling among other symptoms. The increase in volume in the left atrium also causes enlargement of this chamber and can result in cardiac arrhythmias such as atrial fibrillation, which manifest as palpitations – putting the patient at risk for stroke.

Diagnosis of mitral regurgitation starts with the physical exam. Patients usually have a harsh murmur present throughout systole, best heard at the apex. Ultimately, the diagnosis is made on echocardiography. The severity of mitral regurgitation is assessed based on color doppler flow with the use of quantitative measurements, as well as presence or absence of flow reversal in pulmonary veins (Figure2).

Diagnostics for Mitral Valve regurgitation

Figure 2 – Color doppler flow with quantitative measurements to determine severity of Mitral Valve Regurgitation

Generally, pathology of the mitral valve resulting in mitral regurgitation is classified into two separate categories; degenerative and functional.

In degenerative (primary) mitral regurgitation, the pathology involves the mitral valve itself causing malcoaptation of the leaflets. This could be the result of prolapse of one or both leaflets during systole, among other pathologies.

In functional mitral regurgitation, the mitral valve malcoaptation is due to the disease of the left ventricle. For example, patients with advanced congestive heart failure can have dilated left ventricles. This dilation can also stretch the mitral valve annulus and cause malcoaptation of the valve leaflets in systole (Figure3).

Types of Mitral Valve Regurgitation

Figure 3 – Examples of primary and functional mitral valve regurgitation.

Traditionally, surgical repair is shown to be superior to replacement in degenerative mitral regurgitation, while this distinction is not present in functional regurgitation. During repair, the surgeon uses multiple techniques to assure appropriate coaptation of the leaflets during ventricular contraction. Excision of part of the leaflet, suturing part of the leaflets together, and placing a ring along the valve annulus or rearranging the valvular chords are some of these techniques. Mitral valve replacement involves excising the native valve and replacing it with either a bio or mechanical prosthesis.

Over the past decade transcatheter techniques have been developed to mimic surgical ones. In the majority of these techniques, devices are advanced through the femoral vein from the patient’s leg to the mitral valve, avoiding any incisions.

Currently, the most studied and only commercially available transcatheter repair device is MitraClip. By using MitraClip (Figure4), the interventionalist tries to mimic the surgical technique of suturing part of the leaflets together by advancing a clip from the femoral vein and delivering it to the leaflets.

MitraClip

Figure 4 – MitraClip for transcatheter mitral valve therapy.

This delivery would require making a small hole in the intra-atrial septum, enabling the operator to deliver the device from the right side of the heart to the left. In the appropriate patient and in experienced hands, severe mitral regurgitation can be reduced to trace or mild, resulting in improvement of the patient’s symptoms as well as prognosis.  Multiple trials have shown that MitraClip is superior to medical therapy alone in patients with both functional as well as degenerative mitral regurgitation who are at high surgical risk.

While MitraClip is the only commercially available device currently in the US, many other devices are being investigated in different trials. Most of these devices try to duplicate other surgical techniques such as annuloplasty or chordal repair through transcatheter means.

Enthusiasm for transcatheter methods to treat mitral regurgitation is not limited to repair techniques. There is a lot of research focus on replacing the mitral valve without surgery. One area in which this is commercially available is in patients who have already had a mitral valve replacement with a bioprosthesis. Transcatheter methods can be used for therapy, should the initial bioprosthesis degenerate over time. In most cases a new valve can be delivered inside the degenerated one safely – the bioprosthetic valve functioning as the anchor for the new valve (Figure5).

Transcatheter Mitral Valve Repair

Figure 5 – Transcatheter therapy to address degenerative mitral valve bioprosthesis.

Unfortunately, the lack of appropriate anchoring is a major obstacle to replace a native mitral valve with severe regurgitation. The other obstacle is the potential obstruction of the blood flow path out of the heart by native leaflets that can be pushed into the left ventricular outflow track by the new valve. Different methods and devices are being developed and investigated to alleviate these obstacles.

In summary, while the MitraClip has matured into a valuable tool to treat mitral regurgitation in appropriate patients suffering from the condition, other modalities are actively being evaluated in trials for their safety and efficacy. Transcatheter techniques to treat mitral regurgitation are sure to expand as some of these techniques prove both safe and efficacious.

The Structural Heart Team at Carient Heart & Vascular has treated many patients with mitral regurgitation and is involved in a number of trials involving the mitral valve.

Dr. Shawn Yazdani has served as the primary investigator in many of the trials observing transcatheter therapy in patients at high or prohibitive risk for surgical valve replacement. To obtain more information or to schedule a consultation, please call 888-602-3339.

Aortic Stenosis and the Role of Catheter Based Therapies

When Less Invasive TAVR is Preferable in the Treatment of this Serious Heart Condition

Aortic valve disease is one of the most encountered structural abnormalities of the heart.  The aortic valve is a trileaflet structure that separates the left ventricle from the aorta. In systole, during left ventricular contraction, the aortic valve opens between 3 -5 cm2 to allow blood flow.

Aortic valve disease is one of the most encountered structural abnormalities of the heart.  The aortic valve is a trileaflet structure that separates the left ventricle from the aorta. In systole, during left ventricular contraction, the aortic valve opens between 3 -5 cm2 to allow blood flow through the aorta and to the rest of the body.

The most common disease of the aortic valve is aortic stenosis. Aortic stenosis is the result of calcification and narrowing of the aortic valve. As a result, the valve does not open adequately in systole, causing strain and pressure overload on the left ventricle. Aortic stenosis is the result of active inflammation of the valve, which in many ways is similar to atherosclerosis.

Risk factors for developing aortic sclerosis include hypertension, high cholesterol, diabetes and chronic kidney disease. There is perhaps also a genetic predisposition to developing aortic stenosis. Aortic stenosis is more prevalent in the older population. It is mostly diagnosed and treated in patients in their 70’s and 80’s. It is estimated that over six percent of the population in the United States over the age of 70 suffer from aortic stenosis. However, aortic stenosis can present earlier if the patient is born with an abnormal valve such as an unicuspid or bicuspid valve. In these instances, symptoms develop earlier in the fifth and sixth decade of life.Healthy Aortic Valve

Symptoms of aortic stenosis include chest pain, shortness of breath and palpitation. If left untreated, it can ultimately cause congestive heart failure and loss of consciousness – and ultimately sudden cardiac death. The three-year prognosis in aortic stenosis is extremely poor once the patient has developed symptoms.

Diagnosis of aortic stenosis hinges on a physical examination and noninvasive diagnostic cardiac testing such as echocardiography.  Severe aortic stenosis results in a harsh systolic murmur heard best on the left sternal border. The second heart sound is also blunted or absent in this area. Echocardiography shows thickening and calcification of the valve with significantly reduced mobility in systole. The ultimate diagnosis is made by measuring pressure gradient across the aortic valve, utilizing Doppler Wave Echocardiography. A mean gradient of over 40 mmhg, or a valve area of less than 1 cm square, strongly predicts severe aortic stenosis.Aortic Valve Assessment

Treatment of aortic stenosis requires active intervention. Medical therapy alone does not resolve the severe narrowing of the valve. Traditionally, patients have required open heart surgery to replace the narrowed valve with either a bioprosthesis or a mechanical valve. This would require a sternotomy and 4-6 weeks of recovery post operation.

Over the past decade, though, a new technique utilizing transcatheter methods has been shown to be either equivalent or superior to surgical replacement in most patients regardless of their surgical risks. During this procedure commonly known as Transcatheter Aortic Valve Replacement (TAVR), a new valve is advanced from the femoral artery in the groin (in most instances) and placed inside the narrowed valve. There is no surgical incision during TAVR, therefore recovery is much faster.Transcatheter Aortic Valve Replacement

 

Patients undergoing TAVR need elaborate work up prior to their procedure. Aortic valve size needs to be determined prior to the procedure, unlike the traditional procedure when the surgeon decides on valve size during the surgery. While most valves are delivered through the femoral arteries, there are instances where femoral arteries are either too small or diseased to accommodate delivery of the valve. In these instances, alternative access should be utilized to deliver the valve.

A gated CT angiography is essential to address sizing and access before the procedure. Cardiac catheterization is also needed to define patency of the coronary arteries before the procedure. Significant coronary artery disease usually needs to be addressed prior to TAVR. There are currently three commercially available TAVR valves. Which valve to use depends on the anatomical and clinical characteristics of each individual patient for optimal outcome.

Finally, TAVR in lieu of surgical aortic valve replacement (SAVR) is determined on a case by case basis. For example, a patient with extensive multivessel coronary artery disease (CAD), who will need coronary bypass surgery, should also have SAVR at the same time. Some patients with bicuspid aortic valve also have ascending aortic dilatation and will need surgical repair of their aorta, which can be done at the time of SAVR.

Lastly, there are patients who can go either route depending on their circumstances. For example, a younger patient with a small aortic valve might undergo TAVR now. But it is conceivable that their TAVR valve will deteriorate over the next decade or two and they will need another procedure. The small size of the aortic valve might prohibit another TAVR procedure down the line. So, this patient might decide to have a TAVR now and reserve SAVR for a later time, or, alternatively, do the reverse depending on the circumstances. That is why it is important that the treatment recommendation is made after input from every member of the valve team, including an interventional cardiologist as well as a cardiac surgeon.

 

Tricuspid Valve Therapies

Tricuspid regurgitation (TR) has generally been ignored in the therapeutic algorithm of patients with heart disease. There are several reasons for that.

Perhaps the most common reason is that almost 90 percent of patients with severe tricuspid regurgitation (TR) have left-sided heart disease such as mitral valve disease or left ventricular systolic dysfunction. In these instances the TR is thought to be a bi-product of the left-sided disease and most therapies are directed at addressing the left-sided disease.

There is also no effective therapy in the treatment of tricuspid regurgitation. As a matter of fact the most prescribed treatment for this disease is a diuretic. This is in part because surgical literature has shown that patients with primary TR who undergo surgical repair/replacement have higher mortality as well as morbidity compared to other valvular therapies. As a result cardiologists are reluctant to recommend corrective surgery in patients with secondary TR unless the patient was undergoing surgery for another cardiac condition at the same time.

However, there has been a paradigm shift over the past few year in our approach to the treatment of severe TR. A major part of this shift is due to the proliferation of transcatheter techniques in the treatment of other valvular heart diseases such as mitral and aortic valve.

It is observed that patients do worse after transcatheter aortic replacement or transcatheter mitral repair if they have concomitant tricuspid regurgitation. This is in line with the data from the surgical literature. As a result, there is an explosion in device development for percutaneous treatment of tricuspid regurgitation to be done either alone or in conjunction with percutaneous treatment of other valvular heart diseases. Many feasibility trials are currently looking at safety of these devices and a few trials are either ongoing or starting to look at their efficacy.

MitraClip developed to treat mitral regurgitation remains also the most prevalent device used to treat TR in the worldwide registry.

 

 

 

 

 

 

 

 

 

 

 

 

 

Nevertheless, the road ahead from diagnosis to treatment of TR is certainly torturous and long and perhaps it will take many years for us to have a clear understanding of when and how to treat this disease entity.

For one, the timing of intervention to give the patient the best prognosis is poorly understood. In most surgical trials, patients had advanced disease at the time of the operation. It is postulated that intervention should be done earlier in the disease course to give patients the best prognosis. However, the exact timing for transcatheter intervention remains a point of discussion.

Currently surgical correction is considered in patients based on the annular diameter of the tricuspid valve. This might not be the best surrogate marker to assess the severity of tricuspid regurgitation effect on the right ventricle. Many other parameters are being investigated to determine the deleterious effects of TR on the right ventricule. Echocardiographic measurements such as right ventricular strain are among such parameters.

Longitudinal follow up of these parameters will make it more clear as to when to intervene in the disease process to obtain the best prognosis.

The other obstacle in the treatment of TR is the tricuspid valve’s anatomy. It is comprised of three unequal very thin leaflets, the anterior leaflet the longest and posterior leaflet the shortest. Its location and thin nature of the leaflets make echocardiographic imaging especially difficult during any transcatheter procedure.

Optimal intraprocedural imaging is essential in successfully treating the valve. The development of intracardiac imaging as part of the percutaneous devices currently being developed should alleviate some of this difficulty.

Finally, the proximity of other cardiac structure to the tricuspid valve should be taken into account while planning for transcatheter intervention. The right coronary artery is positioned to the lateral aspect of the valve and conduction system to the septal portion. Therefore, the risk of right coronary perforation or inducing conduction disturbance during the procedure should be taken into account. Obtaining a cardiac CT and meticulously evaluating the tricuspid valve and its relationship to other cardiac structures is of paramount importance prior to most percutaneous therapies.

Anatomy of the tricuspid valve and its relationship to other cardiac structures.

 

 

 

 

 

 

 

 

 

Tricuspid valve pathology is perhaps the last valvular pathology to be addressed by transcatheter techniques. There are a lot of challenges ahead as outlined above. Perhaps that is why tricuspid intervention is one of the more exciting fields to be involved in at this time. Also, its treatment could be the most rewarding for the patients as well as physicians.

Watch our recent video presentation on Tricuspid Regurgitation.