What is the management and treatment approach for patients undergoing Transcatheter Edge-to-Edge Repair (TEER) for mitral regurgitation?

From the Guidelines

The management and treatment approach for patients undergoing Transcatheter Edge-to-Edge Repair (TEER) for mitral regurgitation involves comprehensive pre-procedural assessment, periprocedural care, and long-term follow-up, with a focus on optimizing heart failure medications and careful monitoring to prevent complications, as recommended by the most recent guidelines 1.

Key Considerations

• Patients should undergo thorough cardiac imaging, including transesophageal echocardiography, to confirm anatomical suitability for TEER.
• Antiplatelet therapy with aspirin 81-325 mg daily should be continued indefinitely post-procedure.
• During the periprocedural period, antibiotic prophylaxis should be administered 30-60 minutes before the procedure.
• Heparin should be used during the procedure to maintain an activated clotting time >250 seconds.
• Post-procedure, dual antiplatelet therapy with aspirin and clopidogrel 75mg daily is recommended for 1-6 months, followed by lifelong aspirin.
• Endocarditis prophylaxis is indicated for at least 6 months post-TEER.
• Heart failure medications should be optimized based on left ventricular function, including beta-blockers, ACE inhibitors/ARBs, and diuretics as needed.
• Regular follow-up with echocardiography is essential at 1,6, and 12 months, then annually to assess device function and residual regurgitation.

Patient Selection

• TEER is recommended for patients with severe primary MR and high/prohibitive surgical risk, as well as for patients with secondary MR still symptomatic despite optimal guideline-directed medical therapy (GDMT) 1.
• The optimum selection of candidates requires comprehensive assessment and multidisciplinary team (MDT) discussion.

Complications and Monitoring

• TEER is typically performed in high-risk patients with significant comorbidities who require careful monitoring to prevent complications such as device thrombosis or recurrent mitral regurgitation.
• Regular follow-up is essential to assess device function and residual regurgitation, and to optimize heart failure medications as needed.

From the Research

Management and Treatment Approach for Mitral TEER

The management and treatment approach for patients undergoing Transcatheter Edge-to-Edge Repair (TEER) for mitral regurgitation involves several key considerations:

• Choosing the best device for the individual anatomic properties of the patients and considering comorbidities is crucial for maximized mitral regurgitation (MR) reduction, minimalized complication rates, and thus optimized postinterventional prognosis 2.
• TEER is an established procedure for managing mitral regurgitation (MR) in high-risk patients, effective in treating both primary and secondary MR 3.
• The less invasive nature of TEER, along with its high safety profile and immediate haemodynamic improvement, suggests potential benefits in high-risk populations who are not normally included in major trials 3.

Patient Selection and Outcomes

Patient selection is critical for optimal outcomes:

• High-volume mitral valve repair centers have better outcomes than low-volume centers, but whether mitral valve repair volume predicts TEER outcomes remains unknown 4.
• TEER can be safely performed in centers with low volumes of mitral valve repair, but 1-year mortality and heart failure readmission are superior at centers with higher mitral valve repair volume 4.
• Real-world data on peri-procedural outcomes of TEER show favorable safety, with vascular complications, ischemic strokes, cardiac arrests, and tamponades each <1%, and mortality at 1.6% 5.

Technological Advances and Operator Experience

Technological advances and operator experience have improved the safety and efficiency of TEER:

• The development and refinement of new TEER device generations offer the possibility to treat a wide range of mitral valve anatomies 2.
• Improvements in intraprocedural imaging have led to an expansion in the use of transcatheter edge-to-edge repair to more complex mitral valve pathologies and clinical scenarios 6.
• Stepwise improvements in the MitraClip® system between 2016 and 2019 have contributed to decreased hospital length of stay, adverse discharges, and hospital costs 5.