Interventional procedure overview of off-pump minimal access mitral valve repair by artificial chordae insertion to treat mitral regurgitation
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The procedure, condition, current practice and unmet need
The procedure
This transcatheter (minimal access) procedure for mitral regurgitation is done on a beating heart with no need for cardiopulmonary bypass. With the person having treatment under general anaesthesia and using TOE, a left sided anterior thoracotomy is used to advance the device delivery system into the left side of the heart to the target mitral valve leaflet. Once it is correctly positioned, a needle is released with a synthetic chord which is anchored to the surface of the target mitral valve leaflet. The delivery system is removed, and the suture is tightened. Additional chordae can be placed if necessary. Typically, three to four are placed along the free edge of the mitral valve leaflet to re-suspend the prolapsed segment. The tension on the chord is adjusted under TOE guidance until there is improvement or elimination of the mitral regurgitation. Once confirmed on imaging, the endings of the chord sutures are secured to the pericardium. This procedure has a lower risk of compromising subsequent surgical mitral valve repair than some other transcatheter techniques for mitral regurgitation. It may also be suitable for people for whom open-heart surgery is not considered safe due to other health conditions.
The condition
The mitral valve allows blood to flow from the left atrium to the left ventricle. MR happens when the valve doesn't close properly, allowing blood to flow back into the atrium from the ventricle during systole (when the heart contracts). The heart must work harder, resulting in an enlarged left ventricle. If not treated, this can lead to problems including heart failure. MR can be degenerative (primary or structural) or functional (secondary). Degenerative MR is caused by 'wear and tear' to the chords and leaflets in the valve. In functional MR the chords and leaflets are structurally normal but there is geometrical distortion of the subvalvular apparatus caused by idiopathic cardiomyopathy or weakening of the cardiac walls caused by coronary artery disease (ischaemic MR).
Current practice
Degenerative MR is typically managed with open-heart surgery to repair or replace the mitral valve. This procedure requires a sternotomy to access the heart and the use of cardiopulmonary bypass. Functional MR can be managed conservatively with medical therapy aimed at treating heart failure, but this approach is not curative. Surgical procedures such as undersized annuloplasty may also be an option. People with MR of either cause are usually older (typically over 70 years) and frail, with multiple comorbidities. This increases the perioperative risks of morbidity and mortality for open heart surgery. For these people, transcatheter mitral valve repair by artificial chordae may be an appropriate treatment option.
Unmet need
Open-heart surgery is the conventional approach for mitral valve repair or replacement. However, this approach may pose excessive risk for certain people, particularly those who are older, frail, or who have multiple or complex comorbidities. For people for whom open-heart surgery is excessively risky, minimally invasive surgical approaches have been developed, such as transcatheter artificial chordae insertion, which can often be performed through smaller incisions and without the need to stop the heart or use cardiopulmonary bypass. These options aim to reduce perioperative risk and improve recovery, although they may not be suitable for all anatomical presentations of mitral regurgitation.
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