Transcatheter Mitral Valve Replacement Using Annular Reduction by Cinching With TEER in the Commissure (ARCTIC)

Circ Cardiovasc Interv. 2024 Nov;17(11):e014224. doi: 10.1161/CIRCINTERVENTIONS.124.014224. Epub 2024 Nov 6.

Abstract

Background: Mitral annular calcification with valve dysfunction remains a challenging syndrome. Operative risk is high, and available transcatheter therapies are limited.

Methods: This study describes our initial experience with a novel procedure to address large mitral annuli when no surgical or trial-based transcatheter mitral valve replacement device is available. The rationale was to shorten the intercommissural distance using commissural mitral transcatheter edge-to-edge repair (TEER) followed by valve-in-mitral annular calcification transcatheter mitral valve replacement with a balloon-expandable aortic valve platform. Patients with long intercommissural distances and large mitral annulus areas were selected based on a high perceived risk of transcatheter valve embolization. Patients underwent mitral TEER with MitraClip in a commissural position, followed immediately by transseptal transcatheter mitral valve replacement with a 29 mm SAPIEN 3 valve.

Results: Thirteen patients were included. Median intercommissural distance and annular area were 39.1 mm and 930 mm2, respectively. Commissural mitral TEER was successful in all patients with no instances of single leaflet detachment. In 10 of 13 instances, an NTW device size was used. In 12 of 13 patients, valve implantation was successful, including 1 case that required a second valve for atrial positioning of the first valve. In 1 case, frank valve embolization into the left atrium occurred. Among the 12 successful cases, paravalvular leak was 1+ or less, and there were no instances of paravalvular leak adjacent to the TEER device.

Conclusions: In patients with large annuli and sufficient annular calcium, a hybrid mitral TEER and valve replacement with the SAPIEN platform can be successfully used to facilitate transcatheter mitral valve replacement.

Keywords: heart valve diseases; humans; mitral valve; mitral valve insufficiency; mitral valve stenosis.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Calcinosis* / diagnostic imaging
  • Calcinosis* / surgery
  • Cardiac Catheterization* / adverse effects
  • Cardiac Catheterization* / instrumentation
  • Female
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Heart Valve Prosthesis Implantation* / instrumentation
  • Heart Valve Prosthesis*
  • Humans
  • Male
  • Middle Aged
  • Mitral Valve Annuloplasty / adverse effects
  • Mitral Valve Annuloplasty / instrumentation
  • Mitral Valve Insufficiency / diagnostic imaging
  • Mitral Valve Insufficiency / physiopathology
  • Mitral Valve Insufficiency / surgery
  • Mitral Valve* / diagnostic imaging
  • Mitral Valve* / physiopathology
  • Mitral Valve* / surgery
  • Prosthesis Design*
  • Recovery of Function
  • Time Factors
  • Treatment Outcome