new technologies for Mitral regurgitation

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new technologies for Mitral regurgitation

  1. 1. Cosa possiamo fare, nella insufficienza mitralica, oltre la MitraClip. Francesco Maisano MD, FESC Ospedale San RaffaeleDipartimentoCardiotoracovascolare
  2. 2. MitraClip in the clinicalpractice Opportunity Challenges– Largeunmetneed – Lackofevidence, parti– Reportedclinical cularlyfor FMR benefit in – Limitedclinicalexperi selectedpatients ence, concentrated in high volume centers – Limitedapplicability
  3. 3. MitraClip anatomical patient selection considerationsRecommended criteria1• 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 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).
  4. 4. Anatomic MeasurementsP=0.05 P=0.1 San Raffaele Preliminary data
  5. 5. Tenting area and QRS duration p=0.002 P=0.01 San Raffaele Preliminary data
  6. 6. Jet extension (%) p=0.01Jet extension/IC diameter
  7. 7. What to do in patients beyond MitraClip feasibility• Surgery• Synergistic approaches• New technologies – Annuloplasty – Neochordae implantation – Mitral valve replacement
  8. 8. The Mitraclip is applicable only in selected patients Surgeons use many different techniques to individualize treatment2008-Hugo Vanermen
  9. 9. Current transcatheter technologies to treat MR at the leaflet leveltechnique device statusEdge-to-edge MitraClip CE mark Mobius Earlyclinical Mitraflex preclinicalneochordae Neochord Early clinical Babic preclinical Mobius preclinical Valtech - vchordal preclinicalTissue reduction Thermocool preclinicalSpacer Percupro Early clinical
  10. 10. Neochord Inc.
  11. 11. FB, 85 yo, high surgical risk
  12. 12. Neochord Good Bad• “Anatomical” off • Limited applicability pump correction of • Apical attachment of prolapse the neochorda• Minimally invasive • Need for approach annuloplasty• Beating heart adjustment of chordae
  13. 13. Beyond Mitraclip - Annuloplasty• Lackof annuloplasty isassociatedtoacceleratedfailure in the overallsurgicalpopulation Maisano F, et al Eur J CardiothoracSurg. 1999;15:419-25 Gillinov et al J ThoracCardiovascSurg 1998;116:734-43
  14. 14. Transcatheter annuloplasty Coronary sinus remodeling SL dimensions cinching RF/Ultrasound remodeling External compression Direct annuloplasty
  15. 15. Coronary sinus devices MONARC Two-anchor design EVOLUTION (Edwards with chronic trial Lifesciences reshaping (6weeks) (69 pts LLC) by a foreshortening enrolled) bridge CARILLON Acute reshaping AMADEUS trial (Cardiac device acting in (43 pts Dimensions P2P3, repositionable, enrolled ) Inc) retrievable PTMA Tri-lumen catheter, PTOLEMY (Viacor Inc) reshapable, (24 pts possibility of enrolled) multiple long term adjustment
  16. 16. Direct annuloplastythe only approach with a proven surgical backgroundMitralign GDS ValtechBident Accucinch Cardioband• Arterial access • Arterial access • Venous access• Transannular • Subannular • Annular fixation cinchin cinching
  17. 17. Valtech Cardio - CARDIOBAND• A surgical ring implanted percutaneously
  18. 18. Transcatheter MVR• Larger device• Anchoring• Asymmetric anatomy• Interaction with the aortic valve and LVOT• PVL more problematic
  19. 19. Trattamento della valvola tricuspide
  20. 20. Treating valve disease in the future today Patient-optimized care Minimally Transcatheter Open heart invasive interventions procedures surgery Tailored approach – the best option for the patient
  21. 21. Individualizethe 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

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