State of the Art: Transcatheter Edge-to-Edge Repair for Complex Mitral Regurgitation

Highlights•MR is a heterogeneous condition with several etiologies and anatomic variations.•Echocardiography is important to assess if MR is primary or due to LV dysfunction.•Transcatheter edge-to-edge MV repair mimics surgery, creating a double-orifice valve.•Experience, imaging, and new devices allow for MV repair in complex mitral disorders.•Collaboration between the interventionalist and imager is key to treating complex MR.AbstractTranscatheter edge-to-edge mitral valve repair has revolutionized the treatment of primary and secondary mitral regurgitation. The landmark EVEREST (Endovascular Valve Edge-to-Edge Repair Study) and COAPT (Clinical Outcomes Assessment of the MitraClip Percutaneous Therapy for High Surgical Risk Patients) trials included only clinically stable patients with favorable mitral valve anatomy for edge-to-edge repair. However, since its initial commercial approval in the United States, growing operator experience, device iterations, and 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, many of which were previously considered contraindications for the procedure. Because patients with prohibitive surgical risk are often older and present with complex mitral valve disease, knowledge of the potential effectiveness, versatility, and technical approach to a broad range of anatomy is clinically relevant. In this review the authors examine the current experience with mitral valve transcatheter edge-to-edge repair in various pathologies and scenarios that go well beyond the EVEREST II trial inclusion criteria.