TMVR – Transcatheter Mitral Valve Replacement
TMVR, also known as transcatheter mitral valve replacement is a way of replacing the mitral valve in the heart without the need for conventional open-heart surgery. TMVR transcatheter mitral valve replacement is a treatment for mitral valve stenosis (tight mitral valve) or mitral valve regurgitation (leaky mitral valve) or a mix of the two. TMVR transcatheter mitral valve replacement was developed initially as a method of replacing the mitral valve in patients considered too high risk for surgery but will likely replace mitral valve replacement surgery in the future as the technology improves and the outcomes are proved.
TMVR – Dedicated Transcatheter Mitral Valve Replacement Systems
In the last few years there has been a flurry of activity by major device companies to acquire and advance transcatheter mitral valve replacement technology companies and move the field of TMVR from concept to reality. There are now a number of valves in trials that have been developed specifically for the mitral valve space. The challenges that face transcatheter mitral valve replacement are much greater than those of the aortic valve simply because the mitral valve is such a complex structure. Early results are very promising however and the challenges appear to be surmountable.
Current transcatheter mitral valve replacement TMVR systems that have been implanted in humans include:
Tendyne / Intrepid / Fortis / Navigate / CardiaQ / Tiara
These TMVR valves are all still in their relative infancy and only available in the setting of clinical trials. It will be a few years before the impact and success of these valves is known.
TMVR – Transseptal vs. Transapical Access vs. Transatrial Access
Transseptal access is performed through the femoral vein of the leg and is the least invasive of all the implantation methods. No surgical access is required and the recovery time is fast. Technical expertise is required and the transseptal approach for transcatheter mitral valve replacement is technically challenging as compared to other approaches. Transseptal approaches are widely used in a number of cardiac procedures in addition to TMVR, including watchman device and Mitraclip procedure.
Transapical access involves a small surgical incision on the chest wall on the left hand side through which a valve is passed up in to the mitral position. Advantages of this approach to TMVR include much easier valve positioning. The major disadvantage is a direct cardiac incision and related complications. Many of the current options for dedicated transcatheter mitral valve replacement devices use the transapical approach however it is most likely that over time this transitions toward transseptal delivery.
Transatrial access is more involved than the other approaches and is similar in many ways to a standard cardiac surgical approach. See the robotic approach for a description.
TMVR – Hybrid Robotic Approach
Princeton Baptist Medical Center, Birmingham, Alabama is a pioneer of this approach of transcatheter mitral valve replacement. Using the surgical robot small ports is used to obtain access to the right atrium chamber of the heart for the TMVR. The anterior leaflet of the mitral valve is resected and then under direct visualization a transcatheter valve is placed in position then inflated. Stitches are placed to prevent leak and allow fixation of the valve. The disadvantage of this approach is the need for cardiac bypass and surgical technique. The major advantages are elimination of leak and stabilization and direct positioning of the valve.
mitral valve in mac robotic
TMVR – Transcatheter Mitral Valve In Prosthetic Valve Procedures
Transcatheter Mitral Valve In Prosthetic Valve procedures are where a transcatheter valve is placed inside an existing surgically implanted mitral tissue valve. Prosthetic heart valves can either fail by becoming too tight (prosthetic mitral stenosis) or too leaky (prosthetic mitral regurgitation). The two main access sites for this form of TMVR are transapical and transseptal. For those with the technical ability, transseptal is associated with a much faster recovery. In general these procedures as with other transcatheter mitral valve replacement procedures are reserved for patients who are considered high risk for standard cardiac surgery. Outcomes of transcatheter mitral valve in valve procedures are considered promising and acceptable.
mitral valve in valve procedure
TMVR – Transcatheter Mitral Valve In Ring Procedures
Mitral rings are used as part of a standard surgical mitral valve repair procedure. In mitral valve in ring procedures a transcatheter mitral valve is placed inside a failing ring repair. The treatment is usually for mitral valve regurgitation for failed repair. TMVR Transcatheter mitral valve in ring procedures are much more technically difficult and unpredictable as compared to transcatheter mitral valve in valve procedures. The two main access sites for this form of TMVR are transapical and transseptal. Transapical is much more common however transseptal is becoming much more common. The outcomes of transcatheter mitral valve in ring procedures are worse than valve in valve procedures with higher risk of complications including outflow tract obstruction, valve malpositioning and valve embolization. All of these are potentially lethal complications of TMVR that can necessitate emergent surgical intervention.
mitral valve in ring procedure
TMVR – Transcatheter Mitral Valve In MAC Procedures
MAC is short for mitral annular calcification and describes the process whereby the mitral valve is infiltrated by calcium. The bad news here is that the calcium can lead to failure of the valve that often becomes tight or leaky. The MAC however can act as an anchor point for the placement of a transcatheter mitral valve. The main access sites are transapical, transseptal or transatrial. The outcomes data for mitral valve in MAC are limited and the complication rate can be significant. Complications including outflow tract obstruction, valve malpositioning and valve embolization may occur. In the future, the dedicated TMVR transcatheter mitral valve replacement systems are likely to be the treatment of choice here.
Shall be ever grateful if you kindly advise me on the basis of following findings of my Echocardiogram report :
IVS-(diaslolic) 7.6mm, pw (dias) – 8.8mm, LV(Diast) – 44.9mm, LV(Systo) – 26.5mm, E. F. – 72%
MITRAL VALVE – – E wave – 1.22m/s, Awave – 1.9m/s, EARatio – 1.79.AROTIC VALVE – –
Peak Value – 1.26m/sec. Peak gradient – 6.3mm Hg. LVOT – – Peak velocity – – 0.79m/Sec. Peak Gradient – 2.5mm Hg. TR-8.6, RVSP-18.6. Good LV Systolic function.
Good RV Systolic function , No AR. Trivial TR. No PAH. No RWMA. Trivial MR. Mild Amvl prolapse with Trivial M R.
Myself – 64 yrs. BMI–22. With good health. Feel no pain in the chest or exhaustion during fast walking. TMT graph is normal.
But even at rest feel tightness onthe left side of the chest, feel breath lessness, get fear, feel dryness on the sternum . It happens now and then during rest time. Severity persists for some 15/20minutes, then gradually get relieved within 2/3hours.Such happens since last 6/7years. Gradually the frequency and gradience is increasing. The Echocardiogram last done on 10.01.18.Tread Mill Test done during last November.
Kindly advise whether there is so concern about the symptoms in relation to mild prolapse of Amvl. I do free hand exercis since child hood, feel no problem. May I continue such exercise. Kindly advise .
The symptoms are likely not related to the mitral valve, prolapse with trivial MR is not likely to cause chest pain on exertion. The treadmill testing is certainly reassuring if normal and if you were able to do a good exercise level without changes on the ekg tracing or reproducible symptoms then that is also reassuring. If your physician has felt that the risk stratification testing is acceptable and has not told you otherwise then exercise should certainly be encouraged.
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Hi there,
Many thanks for sharing this information.
May I ask if a patient (70 years old) has had two open mitral valve replacements (both bovine valves, the last operation was in 2007, the first was in 1960-70s) and had a pacemaker in situ, is TMVR an option at all?
Hi there,
Many thanks for sharing this information.
May I ask if a patient (70 years old) has had two open mitral valve replacements (both bovine valves, the last operation was in 2007, the first was in 1960-70s) and had a pacemaker in situ, is TMVR an option at all?
Many thanks
Z
Yes, its a good option.
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My husband had open heart mitral valve surgery in 1998. He now needs a new mitral valve. He is 68yrs.and old. Which procedure do you think would be better for him? Open heart or valve -in-valve? The only thing I don’t like about the valve in valve is in 5-7 years he will probably need another valve. Then being older he will have to have open heart. What are your thoughts?
Thank you.
It depends on the situation. Each case is different. As things stand those who are considered decent surgical candidates should likely have surgery and mitral valve in valve procedures should be reserved for those considered to be high risk.
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Thank you for your opinion.. They told me my husband was not a low risk but not a high risk either. Somewhere in the middle. He has had an embolic stroke and 2 brain aneurysm surgeries all due to endocarditis 20 yrs. ago. Could you give me information on the durability and longevity of the valve replacement if we decide to have the valve in valve surgery? Thank you
I was diagnosed with mitral valve prolapse 09/2005, after the birth of my son. Then while being in the hospital for a month, 11/2017, I was diagnosed with congestive heart failure. I live in an area where the doctors are good but the medical innovations are still a bit behind. I have been having a lot of fluid retention and I have gained upwards of 109lbs in about 2 months! My doctor I currently have suggested broadening my medical help, which has brought me to this site, I guess. I’m nervous given my age and that many of the things we ( my doctor and I) have tried are no longer working. Any help please???
What was felt to be the cause of the heart failure?
I am a 75 year old male. I have a mechanical aorta valve replaced in 6/1998. I had my pericardium removed in 4/1998 I had a pacemaker (2 Wires) implanted in March 2015. I currently have a moderate to severe Mitral Stenosis.
. Left ventricular ejection fraction, by visual estimation, is 35 to 40%.
. Global left ventricular systolic function was moderately to severely decreased.
3. Moderately dilated left atrium.
4. Moderately dilated right atrium.
5. There is no evidence of pericardial effusion.
6. Degenerative mitral valve.
7. Mild to moderate mitral valve regurgitation.
8. Moderate to severe mitral stenosis.
9. The mitral annular calcification is moderate.
10. Mild tricuspid regurgitation.
11. Dilated inferior vena cava.
12. Intact interatrial and interventricular septa appear intact, with no echocardiographic evidence of intracardiac shunting.
13. Mildly elevated pulmonary artery systolic pressure.
14. The dimensionless index by Doppler interrogation is: 0.73 (<0.25 is Severe Prosthetic Valve stenosis)
21. Left ventricular ejection fraction, by visual estimation, is 40 to 45%.
2. Global left ventricular systolic function was moderately decreased.
3. Mild left ventricular hypertrophy.
4. Moderately dilated left atrium.
5. Mildly dilated right atrium.
6. There is no evidence of pericardial effusion.
7. Degenerative and mitral annular calcification mitral valve.
8. Moderate to severe mitral stenosis.
9. The mitral annular calcification is severe.
10. Mild tricuspid regurgitation.
11. Intact interatrial and interventricular septa appear intact, with no echocardiographic evidence of intracardiac shunting.
12. Moderately elevated pulmonary artery systolic pressure.
13. MS has increased compared to echo 2/11/19. EF has decreased from 55% to 40%.
14. The dimensionless index by Doppler interrogation is: 0.76 (<0.25 is Severe Prosthetic Valve stenosis).
31. Global left ventricular systolic function was low-normal.
2. Left ventricular ejection fraction, by visual estimation, is 50 to 55%.
3. Non fixed restrictive, consistent with grade 3 out of 4 pattern of LV diastolic dysfunction.
4. Mildly increased left ventricular internal cavity size.
5. Septal motion is consistent with post-op state.
6. Mild concentric left ventricular hypertrophy.
7. Moderately enlarged right ventricle.
8. Severely dilated left atrium.
9. Mildly dilated right atrium.
10. The mitral annular calcification is moderate to severe.
11. Rheumatic mitral valve.
12. Moderate mitral stenosis.
13. Mechanical prosthesis in the aortic valve position. The aortic valve peak pressure gradient is 13.4 mmHg and the mean pressure
gradient is 7.0 mmHg. The dimensionless index by Doppler interrogation is: 0.73 (<0.25 is Severe Prosthetic Valve stenosis).
14. A pacer wire is visualized in the RV.
15. There is no obvious patent foramen ovale or atrial septal defect present.
16. Mildly elevated pulmonary artery systolic pressure.
17. The estimated right ventricular systolic pressure is 40-45 mmHg.
18. There is no evidence of pericardial effusion.
4SR ? V-paced LBBB
5Aorta Valve replacement, Pericardia removed
I am a candidate for a Mitral Clip?
You would not be a candidate for the mitral clip due to the mitral stenosis. There are a few options available in this setting for high risk surgical candidates that include newer trials of transcatheter valves. In out center a few of these trials are available, there may be some available at experienced centers locally. Regardless, this may be worth pursuing.
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Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.
The best presentation I have seen for many Years
Mervyn Gotsman
Hadassah University Hospital Jerusalem
Thank you, glad you found this useful.
You can follow our twitter at @MustafaAhmedMD
Disclaimer: The comment response is opinion and in no way affiliated with my employer. It is a vague response that is not to be used as direct medical advice and in no way should replace the opinion of a medical provider.