5.1 TMVR: Latest Transeptal Valves and Clinical Outcomes

These proceedings summarize the educational activity of the 17th Biennial Meeting of the International Andreas Gruentzig Society held January 30 to February 2, 2024 in Chiang Rai, Thailand.

Faculty Disclosures     Vendor Acknowledgments

2024 IAGS Summary Document

Statement of the problem or issue

Transcatheter mitral valve replacement (TMVR) has several important issues associated with it (Table 1). First of all, mitral regurgitation (MR) or mitral stenosis (MS) generally are found in extremely sick patients. They are most often elderly and have many comorbidities. As a clinical entity, MR is very heterogeneous; it's not just one disease, and that presents an enormous challenge. There is degenerative MR and functional MR. The degenerative-MR patients are those where the leaflets themselves have problems. In the functional-MR patients, it is not the valve itself that is the issue, it is everything around the valve, like the annulus, or a problem with the ventricle. Do we need the same devices for these? Is there one device that will fix all of these deficiencies? Finally, with these devices, there is need for anticoagulation. And often these are the highest risk patients for bleeding.

Table 1. Problem Areas Associated With TMVR.

Gaps in current knowledge

Just like everything else, the more we know, the more we don't know. For example, functional MR has multiple etiologies, and we don't know if you should treat them all the same way. Should we eliminate MR or just reduce MR? After all, M-TEER is already commercially available. And likewise, for MS, why does MAC develop in general anyway? And why is it always the little old woman that you can't fit a device in that has the worst MAC? Are we just throwing devices at disease processes that we don't truly understand? Technology is advancing so much faster than our knowledge of the underlying disease processes. Furthermore, with TMVR, what do we know about valve leaflet durability? This potentially is a big problem.

Figure. Examples of current transcatheter mitral valves.

Possible solutions and future directions

The directions we might follow in the future:

• • Repair versus replace, may follow the current surgical trends;
  • Developing a bail-out option where repair fails – still avoid surgery;
  • Leaflet splitting technologies and procedures;
  • Intravascular lithoplasty for highly-calcified tissues;
  • Technologies that minimize need for anticoagulation;
  • AI-based algorithms to help choose the right device for the right valve problem

References

1. Hensey M, Brown RA, Lal S, et al. Transcatheter mitral valve replacement: An update on current techniques, technologies, and future directions. JACC Cardiovasc Interv. 2021;14(5):489-500. Epub 2021 Mar 1. doi: 10.1016/j.jcin.2020.12.038