A growing number of transcatheter options are available for the treatment of MR. To date, these strategies are reserved for patients with moderate to severe MR who, due to comorbid disease, are deemed to have prohibitive surgical risk.

The edge-to-edge repair technique (MitraClip and PASCAL devices) directly approximates mitral valve leaflets by placing a metal clip across the middle portions of the anterior and posterior leaflets, thereby leading to double orifice valve with improved competence. This approach mimics a surgical correction known as the "Alfieri stitch," in which a suture is placed in the same position. These devices require femoral venous access and atrial septal puncture.

Percutaneous annuloplasty techniques improve MV coaptation by reducing the size of the mitral valve annulus. Adjustable bands or rings are secured adjacent to the MV in the coronary sinus, LA, or LV (Carillon, Cardioband, and Mitralign devices, respectively). These are then tightened to decrease annular dimensions and improve valvular competence. These devices are delivered via femoral venous or arterial access and might require transseptal puncture.

Nonpercutaneous, transcatheter MV replacement and repair options also exist. The Tendyne device (Abbott Medical) delivers a trileaflet, self-expanding bioprosthetic valve transapically via mini-thoracotomy. The SAPIEN 3 Ultra (Edwards Lifesciences) is a balloon-expandable trileaflet bioprosthetic valve placed femorally and via trans-septal puncture or, if vascular access is precluded, transapically. The latter device is approved for valve-in-valve replacement and treatment of bioprosthetic MR in patients at prohibitive risk of reoperation. Finally, the NeoChord device (NeoChord Inc) utilizes a mini-thoracotomy and transapical approach to place sutures (synthetic "chords") between a prolapsing posterior mitral valve leaflet and the LV apex.

With the exception of the PASCAL device, which can be placed with only fluoroscopy guidance, all of the procedures mentioned previously are performed using general anesthesia with real-time TEE imaging. Invasive blood pressure monitoring and large-bore IV or central venous access are indicated. Defibrillator pads should be placed in anticipation of arrhythmias from intracardiac device manipulation. Adjunctive regional anesthesia techniques can be considered if thoracotomy is required. Patients who are hemodynamically stable show no evidence of procedural complications and who otherwise meet standard criteria can be extubated at the end of the procedure.

References

• Avvedimento M, Tang GHL. Transcatheter aortic valve replacement (TAVR): recent updates. Prog Cardiovasc Dis. 2021;69:73-83.
• Khatib D, Neuburger PJ, Pan S, Rong LQ. Transcatheter mitral valve interventions for mitral regurgitation: a review of mitral annuloplasty, valve replacement, and chordal repair devices. J Cardiothorac Vasc Anesth. 2022;36:3887-3903.