Transcatheter edge-to-edge repair: Operating theories, basic principles, and predictors of prognosis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

PAN Wenzhi , LONG Yuliang ,  ZHOU Daxin ,  GE Junbo

Department of Cardiology, Fudan University Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, 200032, P. R. China;

Corresponding author：

ZHOU Daxin, Email: zhou.daxin@zs-hospital.sh.cn; GE Junbo, Email: jbge@zs-hospital.sh.cn

Keywords：

Mitral regurgitation; transcatheter edge-to-edge repair (TEER); theory; principle

DOI：

10.7507/1007-4848.202206012

Video：

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Mitral regurgitation is one of the most common heart valve diseases. Transcatheter edge-to-edge repair (TEER) is currently the most developed and commonly used interventional technique for mitral regurgitation and is recommended by the latest European and American guidelines for patients who are at high surgical risk. TEER device usually consists of a clamping device and a delivery system. The trajectory of the clamping device is called the trajectory, and the trajectory can be well established with the five dimensions movement of the delivery system: left-right oscillation, anterior-posterior oscillation, overall parallel movement, the clamping device's own clockwise rotation, and vertical up-and-down movement. The delivery system's anteroposterior and lateral oscillations are concentrated on the virtual puncture site. Furthermore, the location of the septal puncture site has a significant impact on the establishemnt of the trajectory. The evulation of three variables and adherence to the "4M principles" are necessary for the successful TEER. The three variables are: the position of the clip in the center of the regurgitation,the arm orientation of the clip perpendicular to the boundary of anterior and posterior leaflets, as well as the appropriate length of clamping. The "4M principles" include favorable valve morphology, residual mitral regurgitation below grade 2+, mean transvalvular pressure≤5 mm Hg, and an appropriate amount of leaflets clamping. Patients' baseline situation, the degree of mitral regurgitation and ventricular remodeling, as well as the valve morphology and the outcome of the procedure, are the factors determining the prognosis of patients after TEER.

Citation： PAN Wenzhi, LONG Yuliang, ZHOU Daxin, GE Junbo. Transcatheter edge-to-edge repair: Operating theories, basic principles, and predictors of prognosis. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(8): 946-952. doi: 10.7507/1007-4848.202206012 Copy

1.	Dziadzko V, Clavel MA, Dziadzko M, et al. Outcome and undertreatment of mitral regurgitation: A community cohort study. Lancet, 2018, 391(10124): 960-969.
2.	Chakravarty T, Makar M, Patel D, et al. Transcatheter edge-to-edge mitral valve repair with the MitraClip G4 system. JACC Cardiovasc Interv, 2020, 13(20): 2402-2414.
3.	Gerosa G, D'Onofrio A, Besola L, et al. Transoesophageal echo-guided mitral valve repair using the Harpoon system. Eur J Cardiothorac Surg, 2018, 53(4): 871-873.
4.	Bapat V, Rajagopal V, Meduri C, et al. Early experience with new transcatheter mitral valve replacement. J Am Coll Cardiol, 2018, 71(1): 12-21.
5.	Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: Executive summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021, 77(4): 450-500.
6.	Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2021, 60(4): 727-800.
7.	Long Y, Pan W, Pan C, et al. Transcatheter mitral valve edge-to-edge repair with a novel system. Int Heart J, 2022, 63(1): 23-29.
8.	Long Y, Pan W, Pan C, et al. Real-time echocardiographic guidance for transcatheter repair noncentral mitral regurgitation using the novel ValveClamp system. J Card Surg, 2021, 36(11): 4378-4380.
9.	Pan W, Zhou D, Wu Y, et al. First-in-human results of a novel user-friendly transcatheter edge-to-edge mitral valve repair device. JACC Cardiovasc Interv, 2019, 12(23): 2441-2443.
10.	Sorajja P, Kanda B, Bae R, et al. Maneuvers for technical success with transcatheter mitral valve repair. Catheter Cardiovasc Interv, 2018, 92(3): 617-626.
11.	潘文志, 龙愉良, 周达新. 经导管缘对缘修复(TEER): 定义、分类及技术更新. 中国介入心脏病杂志, 2022, 30(6): 440-444.
12.	Ives CW, Prejean SP, Vardas PN, et al. Initial experiences with the mitraclip g4: Review of the novel device features. Innovations (Phila) 2021: 15569845211030862.
13.	Garcia-Sayan E, Raghunathan D, Li FM, et al. Initial experience with the fourth generation MitraClip™: Outcomes, procedural aspects, and considerations for device selection. Catheter Cardiovasc Interv, 2021, 98(4): E626-E636.
14.	Singh GD, Smith TW, Rogers JH. Targeted transseptal access for MitraClip percutaneous mitral valve repair. Interv Cardiol Clin, 2016, 5(1): 55-69.
15.	Gammie JS, Wilson P, Bartus K, et al. Transapical beating-heart mitral valve repair with an expanded polytetrafluoroethylene cordal implantation device: Initial clinical experience. Circulation 2016; 134 (3): 189-197.
16.	Lim DS, Kar S, Spargias K, et al. Transcatheter valve repair for patients with mitral regurgitation: 30-Day results of the CLASP sudy. JACC Cardiovasc Interv, 2019, 12(14): 1369-1378.
17.	潘翠珍, 周达新, 潘文志, 等. 经心尖二尖瓣夹合术中经食管二维、三维超声心动图监测及评价规范. 中华超声影像学杂志, 2020, 29(4): 289-294.
18.	Yeo KK, Tan JWC, Muller DW, et al. Asian Pacific Society of Cardiology Consensus Recommendations on the use of MitraClip for mitral regurgitation. Eur Cardiol, 2021, 16: e25.
19.	Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med, 2018, 379(24): 2307-2318.
20.	Kaneko T, Newell PC, Nisivaco S, et al. Incidence, characteristics, and outcomes of reintervention after mitral transcatheter edge-to-edge repair. J Thorac Cardiovasc Surg, 2022, doi: 10.1016/j.jtcvs.2022.02.060. Online ahead of print.
21.	Capodanno D, Adamo M, Barbanti M, et al. Predictors of clinical outcomes after edge-to-edge percutaneous mitral valve repair. Am Heart J, 2015, 170(1): 187-195.
22.	Adamo M, Grasso C, Capodanno D, et al. Five-year clinical outcomes after percutaneous edge-to-edge mitral valve repair: Insights from the multicenter GRASP-IT registry. Am Heart J, 2019, 217: 32-41.
23.	Tamburino C, Buccheri S, Popolo Rubbio A, et al. Feasibility and predictors of early discharge after percutaneous edge-to-edge mitral valve repair. Heart, 2017, 103(12): 931-936.
24.	Obadia JF, Messika-Zeitoun D, Leurent G, et al. Percutaneous repair or medical treatment for secondary mitral regurgitation. N Engl J Med, 2018, 379(24): 2297-2306.
25.	Puls M, Lubos E, Boekstegers P, et al. One-year outcomes and predictors of mortality after MitraClip therapy in contemporary clinical practice: Results from the German transcatheter mitral valve interventions registry. Eur Heart J, 2016, 37(8): 703-712.
26.	Boerlage-vanDijk K, Wiegerinck EM, Araki M, et al. Predictors of outcome in patients undergoing MitraClip implantation: An aid to improve patient selection. Int J Cardiol, 2015, 189: 238-243.
27.	de Marchena E, Badiye A, Robalino G, et al. Respective prevalence of the different carpentier classes of mitral regurgitation: A stepping stone for future therapeutic research and development. J Card Surg, 2011, 26(4): 385-392.
28.	Goliasch G, Bartko PE, Pavo N, et al. Refining the prognostic impact of functional mitral regurgitation in chronic heart failure. Eur Heart J, 2018, 39(1): 39-46.
29.	Godino C, Scotti A, Taramasso M, et al. Two-year cardiac mortality after MitraClip treatment of functional mitral regurgitation in ischemic and non-ischemic dilated cardiomyopathy. Int J Cardiol, 2018, 269: 33-39.
30.	Besler C, Orban M, Rommel KP, et al. Predictors of procedural and clinical outcomes in patients with symptomatic tricuspid regurgitation undergoing transcatheter edge-to-edge repair. JACC Cardiovasc Interv, 2018, 11(12): 1119-1128.
31.	Deferm S, Bertrand PB, Verbrugge FH, et al. Atrial functional mitral regurgitation: JACC review topic of the week. J Am Coll Cardiol, 2019, 73(19): 2465-2476.
32.	Zuern CS, Bauer A, Lubos E, et al. Influence of non-cardiac comorbidities on outcome after percutaneous mitral valve repair: Results from the German transcatheter mitral valve interventions (TRAMI) registry. Clin Res Cardiol, 2015, 104(12): 1044-1053.
33.	Ohno Y, Attizzani GF, Capodanno D, et al. Impact of chronic kidney disease on outcomes after percutaneous mitral valve repair with the MitraClip system: Insights from the GRASP registry. EuroIntervention, 2016, 11(14): e1649-e1657.
34.	Safiriyu I, Nagraj S, Otulana R, et al. Prognostic impact of pre- and post- procedural renal dysfunction on late all-cause mortality outcome following transcatheter edge-to-edge repair of the Mitral Valve: A systematic review and meta-analysis. Cardiovasc Revasc Med, 2022, doi: 10.1016/j.carrev.2022.03.023. Epub ahead of print.
35.	Senni M, Adamo M, Metra M, et al. Treatment of functional mitral regurgitation in chronic heart failure: Can we get a 'proof of concept' from the MITRA-FR and COAPT trials? Eur J Heart Fail, 2019, 21 (7): 852-861.
36.	Grayburn PA, Sannino A, Packer M. Proportionate and disproportionate functional mitral regurgitation: A new conceptual framework that reconciles the results of the MITRA-FR and COAPT Trials. JACC Cardiovasc Imaging, 2019, 12(2): 353-362.
37.	Packer M, Grayburn PA. Contrasting effects of pharmacological, procedural, and surgical interventions on proportionate and disproportionate functional mitral regurgitation in chronic heart failure. Circulation, 2019, 140(9): 779-789.
38.	龙愉良, 潘文志, 周达新. 功能性二尖瓣反流介入治疗的争议与进展. 中华心血管病杂志(网络版), 2021, 4(1): 1-5.
39.	Ben-Shoshan J, Overtchook P, Buithieu J, et al. Predictors of outcomes following transcatheter edge-to-edge mitral valve repair. JACC Cardiovasc Interv, 2020, 13(15): 1733-1748.
40.	Sato H, Cavalcante JL, Bae R, et al. Coaptation Reserve predicts optimal reduction in mitral regurgitation and long-term survival with transcatheter edge-to-edge repair. Circ Cardiovasc Interv, 2022, doi: 10.1161/CIRCINTERVENTIONS.121.011562. Online ahead of print.
41.	Koell B, Ludwig S, Weimann J, et al. Long-term outcomes of patients with elevated mitral valve pressure gradient after mitral valve edge-to-edge repair. JACC Cardiovasc Interv, 2022, 15(9): 922-934.
42.	Patzelt J, Zhang W, Sauter R, et al. Elevated mitral valve pressure gradient is predictive of long-term outcome after percutaneous edge-to-edge mitral valve repair in patients with degenerative mitral regurgitation ( MR ), but not in functional MR. J Am Heart Assoc 2019; 8 (13): e011366.
43.	Yoon SH, Makar M, Kar S, et al. Prognostic value of increased mitral valve gradient after transcatheter edge-to-edge repair for primary mitral regurgitation. JACC Cardiovasc Interv, 2022, 15(9): 935-945.

1. Dziadzko V, Clavel MA, Dziadzko M, et al. Outcome and undertreatment of mitral regurgitation: A community cohort study. Lancet, 2018, 391(10124): 960-969.
2. Chakravarty T, Makar M, Patel D, et al. Transcatheter edge-to-edge mitral valve repair with the MitraClip G4 system. JACC Cardiovasc Interv, 2020, 13(20): 2402-2414.
3. Gerosa G, D'Onofrio A, Besola L, et al. Transoesophageal echo-guided mitral valve repair using the Harpoon system. Eur J Cardiothorac Surg, 2018, 53(4): 871-873.
4. Bapat V, Rajagopal V, Meduri C, et al. Early experience with new transcatheter mitral valve replacement. J Am Coll Cardiol, 2018, 71(1): 12-21.
5. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: Executive summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021, 77(4): 450-500.
6. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J, 2021, 60(4): 727-800.
7. Long Y, Pan W, Pan C, et al. Transcatheter mitral valve edge-to-edge repair with a novel system. Int Heart J, 2022, 63(1): 23-29.
8. Long Y, Pan W, Pan C, et al. Real-time echocardiographic guidance for transcatheter repair noncentral mitral regurgitation using the novel ValveClamp system. J Card Surg, 2021, 36(11): 4378-4380.
9. Pan W, Zhou D, Wu Y, et al. First-in-human results of a novel user-friendly transcatheter edge-to-edge mitral valve repair device. JACC Cardiovasc Interv, 2019, 12(23): 2441-2443.
10. Sorajja P, Kanda B, Bae R, et al. Maneuvers for technical success with transcatheter mitral valve repair. Catheter Cardiovasc Interv, 2018, 92(3): 617-626.
11. 潘文志, 龙愉良, 周达新. 经导管缘对缘修复(TEER): 定义、分类及技术更新. 中国介入心脏病杂志, 2022, 30(6): 440-444.
12. Ives CW, Prejean SP, Vardas PN, et al. Initial experiences with the mitraclip g4: Review of the novel device features. Innovations (Phila) 2021: 15569845211030862.
13. Garcia-Sayan E, Raghunathan D, Li FM, et al. Initial experience with the fourth generation MitraClip™: Outcomes, procedural aspects, and considerations for device selection. Catheter Cardiovasc Interv, 2021, 98(4): E626-E636.
14. Singh GD, Smith TW, Rogers JH. Targeted transseptal access for MitraClip percutaneous mitral valve repair. Interv Cardiol Clin, 2016, 5(1): 55-69.
15. Gammie JS, Wilson P, Bartus K, et al. Transapical beating-heart mitral valve repair with an expanded polytetrafluoroethylene cordal implantation device: Initial clinical experience. Circulation 2016; 134 (3): 189-197.
16. Lim DS, Kar S, Spargias K, et al. Transcatheter valve repair for patients with mitral regurgitation: 30-Day results of the CLASP sudy. JACC Cardiovasc Interv, 2019, 12(14): 1369-1378.
17. 潘翠珍, 周达新, 潘文志, 等. 经心尖二尖瓣夹合术中经食管二维、三维超声心动图监测及评价规范. 中华超声影像学杂志, 2020, 29(4): 289-294.
18. Yeo KK, Tan JWC, Muller DW, et al. Asian Pacific Society of Cardiology Consensus Recommendations on the use of MitraClip for mitral regurgitation. Eur Cardiol, 2021, 16: e25.
19. Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med, 2018, 379(24): 2307-2318.
20. Kaneko T, Newell PC, Nisivaco S, et al. Incidence, characteristics, and outcomes of reintervention after mitral transcatheter edge-to-edge repair. J Thorac Cardiovasc Surg, 2022, doi: 10.1016/j.jtcvs.2022.02.060. Online ahead of print.
21. Capodanno D, Adamo M, Barbanti M, et al. Predictors of clinical outcomes after edge-to-edge percutaneous mitral valve repair. Am Heart J, 2015, 170(1): 187-195.
22. Adamo M, Grasso C, Capodanno D, et al. Five-year clinical outcomes after percutaneous edge-to-edge mitral valve repair: Insights from the multicenter GRASP-IT registry. Am Heart J, 2019, 217: 32-41.
23. Tamburino C, Buccheri S, Popolo Rubbio A, et al. Feasibility and predictors of early discharge after percutaneous edge-to-edge mitral valve repair. Heart, 2017, 103(12): 931-936.
24. Obadia JF, Messika-Zeitoun D, Leurent G, et al. Percutaneous repair or medical treatment for secondary mitral regurgitation. N Engl J Med, 2018, 379(24): 2297-2306.
25. Puls M, Lubos E, Boekstegers P, et al. One-year outcomes and predictors of mortality after MitraClip therapy in contemporary clinical practice: Results from the German transcatheter mitral valve interventions registry. Eur Heart J, 2016, 37(8): 703-712.
26. Boerlage-vanDijk K, Wiegerinck EM, Araki M, et al. Predictors of outcome in patients undergoing MitraClip implantation: An aid to improve patient selection. Int J Cardiol, 2015, 189: 238-243.
27. de Marchena E, Badiye A, Robalino G, et al. Respective prevalence of the different carpentier classes of mitral regurgitation: A stepping stone for future therapeutic research and development. J Card Surg, 2011, 26(4): 385-392.
28. Goliasch G, Bartko PE, Pavo N, et al. Refining the prognostic impact of functional mitral regurgitation in chronic heart failure. Eur Heart J, 2018, 39(1): 39-46.
29. Godino C, Scotti A, Taramasso M, et al. Two-year cardiac mortality after MitraClip treatment of functional mitral regurgitation in ischemic and non-ischemic dilated cardiomyopathy. Int J Cardiol, 2018, 269: 33-39.
30. Besler C, Orban M, Rommel KP, et al. Predictors of procedural and clinical outcomes in patients with symptomatic tricuspid regurgitation undergoing transcatheter edge-to-edge repair. JACC Cardiovasc Interv, 2018, 11(12): 1119-1128.
31. Deferm S, Bertrand PB, Verbrugge FH, et al. Atrial functional mitral regurgitation: JACC review topic of the week. J Am Coll Cardiol, 2019, 73(19): 2465-2476.
32. Zuern CS, Bauer A, Lubos E, et al. Influence of non-cardiac comorbidities on outcome after percutaneous mitral valve repair: Results from the German transcatheter mitral valve interventions (TRAMI) registry. Clin Res Cardiol, 2015, 104(12): 1044-1053.
33. Ohno Y, Attizzani GF, Capodanno D, et al. Impact of chronic kidney disease on outcomes after percutaneous mitral valve repair with the MitraClip system: Insights from the GRASP registry. EuroIntervention, 2016, 11(14): e1649-e1657.
34. Safiriyu I, Nagraj S, Otulana R, et al. Prognostic impact of pre- and post- procedural renal dysfunction on late all-cause mortality outcome following transcatheter edge-to-edge repair of the Mitral Valve: A systematic review and meta-analysis. Cardiovasc Revasc Med, 2022, doi: 10.1016/j.carrev.2022.03.023. Epub ahead of print.
35. Senni M, Adamo M, Metra M, et al. Treatment of functional mitral regurgitation in chronic heart failure: Can we get a 'proof of concept' from the MITRA-FR and COAPT trials? Eur J Heart Fail, 2019, 21 (7): 852-861.
36. Grayburn PA, Sannino A, Packer M. Proportionate and disproportionate functional mitral regurgitation: A new conceptual framework that reconciles the results of the MITRA-FR and COAPT Trials. JACC Cardiovasc Imaging, 2019, 12(2): 353-362.
37. Packer M, Grayburn PA. Contrasting effects of pharmacological, procedural, and surgical interventions on proportionate and disproportionate functional mitral regurgitation in chronic heart failure. Circulation, 2019, 140(9): 779-789.
38. 龙愉良, 潘文志, 周达新. 功能性二尖瓣反流介入治疗的争议与进展. 中华心血管病杂志(网络版), 2021, 4(1): 1-5.
39. Ben-Shoshan J, Overtchook P, Buithieu J, et al. Predictors of outcomes following transcatheter edge-to-edge mitral valve repair. JACC Cardiovasc Interv, 2020, 13(15): 1733-1748.
40. Sato H, Cavalcante JL, Bae R, et al. Coaptation Reserve predicts optimal reduction in mitral regurgitation and long-term survival with transcatheter edge-to-edge repair. Circ Cardiovasc Interv, 2022, doi: 10.1161/CIRCINTERVENTIONS.121.011562. Online ahead of print.
41. Koell B, Ludwig S, Weimann J, et al. Long-term outcomes of patients with elevated mitral valve pressure gradient after mitral valve edge-to-edge repair. JACC Cardiovasc Interv, 2022, 15(9): 922-934.
42. Patzelt J, Zhang W, Sauter R, et al. Elevated mitral valve pressure gradient is predictive of long-term outcome after percutaneous edge-to-edge mitral valve repair in patients with degenerative mitral regurgitation ( MR ), but not in functional MR. J Am Heart Assoc 2019; 8 (13): e011366.
43. Yoon SH, Makar M, Kar S, et al. Prognostic value of increased mitral valve gradient after transcatheter edge-to-edge repair for primary mitral regurgitation. JACC Cardiovasc Interv, 2022, 15(9): 935-945.

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