Trattamento percutaneo della valvulopatia mitralica

ABSTRACT Riassunto La valvuloplastica mitralica percutanea è diventata la migliore opzione terapeutica per la stenosi mitralica, con buoni risultati sia a breve che a lungo termine. Essa è comparabile col classico intervento chirurgico di commissurotomia mitra-lica a cielo chiuso per quanto riguarda l'incremento dell'area valvolare. Per l'insufficienza mitralica, al contrario, fino a poco tempo fa l'unico trattamento disponibile era quello chirurgico, sem-pre più volto alla riparazione valvolare più che alla sostituzione. Alcuni anni fa è stata introdotta una tecnica percutanea di riparazione "edge-to-edge" della valvola mitrale, basata sull'operazione di Alfieri, che crea una valvola a doppio orifi-cio con una migliore coaptazione delle cuspidi. Completato lo studio in fase 1 EVEREST I con incoraggianti risultati, è seguito lo studio EVEREST II. Più recentemente una annuloplastica mitralica percutanea è stata tentata in alcuni pazien-ti; essa consiste nell'impianto di un sistema accorciante nel seno coronarico in considerazione della sua stretta relazione anatomica con l'annulus mitralico. In ogni caso allo stato attuale il trattamento chirurgico conserva il suo ruolo dominante. Summary Percutaneous mitral valvuloplasty has become the primary therapeutic option for mitral stenosis, with good short-and long-term results. It is comparable to surgical closed mitral commissurotomy in terms of valve area increase. For mitral insufficiency, on the contrary, until recently the only treatment available was surgical, with an increasing ten-dency to valve repair instead of replacement. A few years ago a percutaneous "edge-to-edge" mitral valve repair was introduced, based on Alfieri's operation, which creates a double-orifice valve with better cuspid coaptation. The phase I study EVEREST I has been completed with incouraging results, followed by EVEREST II. More recently a percutaneous transvenous mitral annuloplasty has been reported in a few patients, consisting in the implantation of a shortening devi-ce in the coronary sinus in consideration of its proximity to the mitral annulus. However for mitral regurgitation the sur-gical treatment definitely plays the dominant role.

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    ABSTRACT: Left-to-right shunt after percutaneous mitral valvuloplasty was evaluated by contrast echocardiography in 29 patients at 24 hours and at 1, 3, 6, and 9 months after the procedure. The patients were divided into two groups: in group A (13 patients) the double-balloon technique was used; in group B (16 patients) the Inoue single-balloon technique was used. The two groups were comparable in terms of age, gender, and mitral valve area before and after percutaneous mitral valvuloplasty. A left-to-right shunt was detected in all patients 24 hours after the procedure. At 1 month follow-up the shunt was present in 12 patients of group A (92%) and in 13 of group B (81%) with a statistically significant difference (p < 0.001). At 3 months the values were 7 (54%) in group A and 6 (37.5%) in group B (p < 0.05); at 6 months the values were 3 (23%) in group A and 3 (19%) in group B (NS). At 9 months a left-to-right shunt was no longer detectable in any of the patients in either group. The disappearance of the shunt could be related to a healing process of the atrial septal injury that occurs within a few months after percutaneous mitral valvuloplasty. This process seems to be more rapid in group B patients, probably because of the smaller lesion that is produced in the atrial septum by the passage of the Inoue balloon.
    American Heart Journal 03/1993; 125(3):783-6. DOI:10.1016/0002-8703(93)90171-5 · 4.56 Impact Factor
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    ABSTRACT: Mitral annuloplasty is the most common surgical procedure performed for ischemic mitral regurgitation (MR). Surgical mitral annuloplasty is limited by morbidity, mortality, and MR recurrence. We evaluated the safety and feasibility of a transvenous catheter-delivered implantable device to provide a percutaneous alternative to surgical mitral annuloplasty. Five patients with chronic ischemic MR underwent percutaneous transvenous implantation of an annuloplasty device in the coronary sinus. Implantation was successful in 4 patients. Baseline MR in the entire group was grade 3.0+/-0.7 and was reduced to grade 1.6+/-1.1 at the last postimplantation visit when the device was intact or the last postprocedural visit in the patient in whom the device was not successfully implanted. Separation of the bridge section of the device occurred in 3 of 4 implanted devices and was detected at 28 to 81 days after implantation. There were no postprocedural device-related complications. Percutaneous implantation of a device intended to remodel the mitral annulus is feasible. Initial experience suggests a possible favorable effect on MR. Percutaneous transvenous mitral annuloplasty warrants further evaluation as a less invasive alternative to surgical annuloplasty.
    Circulation 03/2006; 113(6):851-5. DOI:10.1161/CIRCULATIONAHA.105.591602 · 14.95 Impact Factor
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    ABSTRACT: This study sought to evaluate the clinical results of a percutaneous approach to mitral valve repair for mitral regurgitation (MR). A surgical technique approximating the middle scallops of the mitral leaflets to create a double orifice with improved leaflet coaptation was introduced in the early 1990s. Recently, a percutaneous method to create the same type of repair was developed. A trans-septal approach was used to deliver a clip device that grasps the mitral leaflet edges to create the double orifice. General anesthesia, fluoroscopy, and echocardiographic guidance are used. A 24-F guide is positioned in the left atrium. The clip is centered over the mitral orifice, passed into the left ventricle, and pulled back to grasp the mitral leaflets. After verification that MR is reduced, the clip is released. Twenty-seven patients had six-month follow-up. Clips were implanted in 24 patients. There were no procedural complications and four 30-day major adverse events: partial clip detachment in three patients, who underwent elective valve surgery, and one patient with post-procedure stroke that resolved at one month. Three additional patients had surgery for unresolved MR, leaving 18 patients free from surgery. In 13 of 14 patients with reduction of MR to < or =2+ after one month, the reduction was maintained at six months. Percutaneous edge-to-edge mitral valve repair can be performed safely and a reduction in MR can be achieved in a significant proportion of patients to six months. Patients who required subsequent surgery had elective mitral valve repair or intended replacement.
    Journal of the American College of Cardiology 12/2005; 46(11):2134-40. DOI:10.1016/j.jacc.2005.07.065 · 15.34 Impact Factor


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