new technologies for mitral regurgitation
Post on 02-Dec-2014
2.431 Views
Preview:
DESCRIPTION
TRANSCRIPT
Cosa possiamo fare, nella insufficienza mitralica, oltre la MitraClip.
Francesco Maisano MD, FESCOspedale San Raffaele
Dipartimento Cardiotoracovascolare
MitraClip in the clinical practice
Opportunity– Large unmet need – Reported clinical
benefit in selected patients
Challenges– Lack of evidence,
particularly for FMR– Limited clinical
experience, concentrated in high volume centers
– Limited applicability
MitraClip anatomical patient selection considerations
• Moderate to severe MR (Grade 3 or more out of 4 grades)
• Pathology in A2-P2 area• Coaptation length > 2 mm
(depending on leaflet mobility)• Coaptation depth < 11 mm• Flail gap < 10 mm• Flail width < 15 mm• Mitral valve orifice area > 4cm2
(depending on leaflet mobility)• Mobile leaflet length > 1 cm
Recommended criteria1
1. The current patient considerations are based on EVEREST II and commercial European experience to date. The MitraClip Patient Selection Coniderations document has been endorsed by Expert Opinion (Crossroads institute).
Anatomic Measurements
P=0.05 P=0.1
San Raffaele Preliminary data
Tenting area and QRS duration
p=0.002
P=0.01
San Raffaele Preliminary data
Jet extension (%)
Jet extension/IC diameter
p=0.01
What to do in patients beyond MitraClip feasibility
• Surgery• Synergistic approaches• New technologies
– Annuloplasty– Neochordae implantation– Mitral valve replacement
2008-Hugo Vanermen
The Mitraclip is applicable only in selected patients
Surgeons use many different techniques to individualize treatment
Current transcatheter technologies to treat MR at the leaflet level
technique device status
Edge-to-edge MitraClip CE mark
Mobius Early clinical
Mitraflex preclinical
neochordae Neochord Early clinical
Babic preclinical
Mobius preclinical
Valtech - vchordal preclinical
Tissue reduction Thermocool preclinical
Spacer Percupro Early clinical
Neochord Inc.
FB, 85 yo, high surgical risk
Neochord
Good• “Anatomical” off
pump correction of prolapse
• Minimally invasive approach
• Beating heart adjustment of chordae
Bad• Limited applicability • Apical attachment of
the neochorda• Need for
annuloplasty
Beyond Mitraclip - Annuloplasty
• Lack of annuloplasty is associated to accelerated failure in the overall surgical population
Maisano F, et al Eur J Cardiothorac Surg. 1999;15:419-25Gillinov et al J Thorac Cardiovasc Surg 1998;116:734-43
Transcatheter annuloplasty
MONARC (Edwards Lifesciences LLC)
Two-anchor design with chronic reshaping (6weeks) by a foreshortening bridge
EVOLUTION trial (69 pts enrolled)
CARILLON (Cardiac Dimensions Inc)
Acute reshaping device acting in P2P3, repositionable, retrievable
AMADEUS trial(43 pts enrolled )
PTMA (Viacor Inc)
Tri-lumen catheter, reshapable, possibility of multiple long term adjustment
PTOLEMY(24 pts enrolled)
Coronary sinus devices
Direct annuloplasty
the only approach with a proven surgical background
Valtech Cardio - CARDIOBAND
• A surgical ring implanted percutaneously
Transcatheter MVR
• Larger device• Anchoring• Asymmetric anatomy• Interaction with the aortic valve
and LVOT• PVL more problematic
Valve in Valve and Valve in Ring
Trattamento della valvola tricuspide
Treating valve disease in the future
Tailored approach – the best option for the patient
today
Individualize the therapy waiting for more evidence
• Anatomy and function• Comorbidities, Life
expectancy• Compare risk and
probability of success• Preservation of surgical
option• Patient informed consent
for therapy• collaboration
top related