Experts at UPMC Presbyterian Shadyside Perform 400th Transcatheter Edge-to-Edge Repair
February 23, 2023
Treatment for mitral valvular regurgitation has greatly advanced in the last two decades. The condition, treatment of which used to require open heart surgery through a sternotomy, can now be treated minimally invasively through transcatheter procedures, expanding access to advanced mitral valvular disease care.
Mitral valvular disease increases in frequency in older patients. When standard therapy presents too many risks and guideline directed medical therapy no longer improves regurgitation, transcatheter edge-to-edge repair (TEER) is an effective alternative, according to A.J. Conrad Smith, MD, medical director, UPMC Center for Heart Valve Disease; associate chief of cardiology for Diversity, Equity, and Inclusion, Division of Cardiology.
Studies have demonstrated that TEER using the MitraClip®System, an FDA approved surgical device, significantly reduces mitral regurgitation and heart failure hospitalizations. In January 2023, cardiovascular experts at UPMC Presbyterian Shadyside performed the centers’ 400th TEER procedure.
Leaders in Transcatheter Edge-to-Edge Repair
In the early 1990s, Italian cardiac surgeon Ottavio Alfieri developed the “Alfieri Stitch,” a novel technique for treating severe mitral regurgitation in people who couldn’t tolerate complex surgical repairs of the mitral valve.
“Dr. Alfieri sutured a portion of the leaflets together – in this case, the A2P2 portion – creating a double orifice,” Dr. Smith says. “He performed this technique on a series of patients and demonstrated that it can significantly and securely decrease regurgitation.”
The TEER technique evolved based on Alfieri’s concept. Using transcatheter technology, a device is guided through the femoral vein to the right atrium and then across the atrial septum into the left atrium. Once in the left atrium, it is carefully positioned over the malcoapting portion of the leaflets, and then the open clip is guided into the left ventricle. The clip is then slowly withdrawn until the leaflets rest on its arms. The device is then closed, pulling the leaflets together to create a double valve orifice, significantly reducing the regurgitation.
In addition to immediate benefits such as reduced surgical trauma and faster recovery time, studies have shown significant improvement in mitral regurgitation grade, New York Heart Association functional class, and a decrease in heart failure hospitalizations for degenerative mitral regurgitation after one year of receiving TEER. For functional mitral regurgitation, the “Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation” (COAPT) trial demonstrated a significant reduction in heart failure hospitalizations and all-cause mortality after two and three years.1
TEER may be appropriate for people with severe primary (degenerative) mitral regurgitation who are poor surgical candidates with comorbidities; and in the case of secondary (functional) mitral regurgitation, whose condition hasn’t improved after three months of guideline directed medical therapy.
“We were a part of one of the earliest studies of the MitraClip®, so we’ve been performing transcatheter edge-to-edge repair with that device since 2013 as part of a COAPT,” Dr. Smith says. “We’ve had the opportunity to have the device as part of a research study and then as part of a continued access registry prior to its clinical approval.”
Comprehensive Valvular Regurgitation Care
As of 2020, more than 30,000 people have been treated with TEER at hundreds of sites across the United States. Yet it's not an optimal treatment for all who suffer from severe mitral regurgitation – several circumstances and anatomical variables may warrant other therapies.
Guideline directed medical therapy and cardiac resynchronization therapy are effective for treating patients who suffer from heart failure with reduced ejection fraction (HFrEF) and severe functional mitral regurgitation, according to Dr. Smith. The COAPT trial demonstrated that in this patient population, TEER should only be considered after three months of maximally tolerated guideline directed medical therapy.1
“In the COAPT trial, mitral regurgitation decreased to a non-severe level for 20% of patients that were on maximally tolerated guideline directed medical therapy,” Dr. Smith says. “The medications work, as does cardiac resynchronization therapy, for those appropriate patients with wide left bundle branch blocks.”
The UPMC Center for Heart Valve Disease collaborates with the Medication Optimization Clinic at the UPMC Advanced Heart Failure Center to effectively and efficiently get patients on guideline directed medical therapy. Mary Keebler, MD, medical director, UPMC Advanced Heart Failure Center, serves as attending physician of the clinic, which is staffed by a multidisciplinary team of heart failure specialists led by Jennifer Kliner, CRNP, and Jim Coons, PharmD, FCCP, FACC, BCCP.
Moreover, it is recommended that other therapies be considered when mitral stenosis is present with regurgitation, mitral leaflets are calcified, and the posterior leaflets cannot be grasped by the clip, among other complex situations. Experts at the UPMC Center for Heart Valve Disease have extensive experience with transcatheter mitral valve replacement (TMVR), minimally invasive mitral valve surgery using robotic instruments, and several additional surgical and non-surgical treatments.
“There is a full range of treatment options for mitral valvular disease,” Dr. Smith says. “At the UPMC Center for Heart Valve Disease, we pride ourselves on being able to care for patients with primary and secondary mitral regurgitation, complex mitral regurgitation, mitral stenosis, and the continuum of mitral valve disease.”
For more information or to refer a patient to the UPMC Heart and Vascular Institute, please email HVIReferral@upmc.edu.
References
- Stone, Gregg W. Lindenfeld, JoAnn. Abraham, William T. Kar, Saibal. Lim, Scott. Mishell, Jacob M. Whisenant, Brian. Grayburn, Paul A. Rinaldi, Michael. Kapadia, Samir R. Rajagopal, Vivek. Sarembock, Ian J. Ch.B. et al. for the COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. New England Journal of Medicine. 2022 Oct.; 379(24): 2307-2318. 2018.
MitraClip® is a trademark of Abbott.
