The transcatheter mitral valve repair (TMVR) programme at Royal Brompton and Harefield hospitals is one of the most experienced and comprehensive in the world. Dr Robert Smith runs the most accomplished MitraClip team in the UK. He has treated more than 250 leaky mitral valves with MitraClip therapy.

Faulty mitral valves are one of the most common causes of cardiovascular disease (CVD) and can be caused by age-related changes to the heart. Experts at Royal Brompton and Harefield Hospitals have been leading the way in recent years to develop lifesaving alternatives for patients who are at increased risk from conventional openheart surgery, or who might benefit from a minimally invasive approach. Human heart valves are exceptional structures. The mitral valve, in particular, is very complex with thin valve leaflets attached to the heart wall via multiple string-like chords. Opening with every heartbeat, millions of times over a lifetime, the valve is susceptible to wear and tear.

What is mitral regurgitation?

As the heart beats, the mitral valve and tricuspid valve control blood flow from the atria to the ventricles. If the mitral valve’s two leaflets do not close completely then this allows blood to flow backwards at high pressure through the valve into the left atrium.

Known as mitral regurgitation (MR), it causes the heart to work harder to push blood around the body. Mitral regurgitation is often associated with heart failure which is one of the most common cardiocvascular disorders worldwide. Patients may experience symptoms such as fatigue, shortness of breath and worsening heart failure. It can also put further pressure on the pulmonary vessels, and in severe cases, this can result in fluid congestion of the lungs.

Mitral regurgitation can be related to age, coronary artery disease, underlying heart muscle disease (cardiomyopathy) or a birth defect.

Treating the leaky valve

Mitral regurgitation can be successfully treated by experts at Royal Brompton & Harefield Hospitals. Conventionally, degenerative mitral regurgitation is treated by open-heart surgery which, in older or frailer patients, can be associated with a higher risk and longer recovery time.

In situations where the risk of surgery is too high, or when the regurgitation is ‘functional’ (i.e. due to a weak heart muscle), open-heart surgery may not be appropriate.

The MitraClip device is a small clip that is attached to the mitral valve. It treats mitral regurgitation by allowing the mitral valve to close more completely, helping to restore normal blood flow through the heart.

As a transcatheter procedure, the MitraClip – created by Abbott Vascular – is a less invasive approach compared to conventional surgery. Using the MitraClip technique, access to the heart is via a small incision in the groin and the mitral valve is repaired through a catheter inserted via the femoral vein.

Once the catheter is guided to the heart, a small hole is made to enable the catheter to cross from the right to the left side of the heart. The MitraClip is then steered into the left atrium. This small device is then used to literally ‘clip’ the leaking portions of the valve leaflets together.

During the procedure to fit the device, a radiographer is on hand with an x-ray machine, to provide the images to guide the interventional cardiologist. In addition, another cardiologist guides a transoesophageal echocardiogram (TOE), which uses ultrasound from a probe to check the structure of the heart and how well it is functioning. This allows for real-time mitral regurgitation reduction assessment on the beating heart, and thereby avoids cardiopulmonary bypass.

The MitraClip device is attached to a highly manoeuvrable delivery catheter.

Quick improvement

The procedure usually takes between two and three hours immediately reduces mitral regurgitation. Patients are likely to feel a change to their quality of life quickly afterwards, once the anaesthetic has worn off.

Recovery is faster than conventional surgery, and MitraClip patients are usually discharged from hospital after a few days.

Dr Smith adds: “After 48 hours, they have a significant improvement. MitraClip is associated with symptomatic improvement in 90 to 95 per cent of patients. It’s proven to be good at relieving symptoms and can generally be performed at low risk of serious complication.”

“More recently, a major study – COAPT* – has demonstrated that MitraClip improves survival and reduces hospital admissions for functional mitral regurgitation.”

A whole team of specialists

Dr Smith highlights the benefit of being treated by an experienced multidisciplinary team at Royal Brompton and Harefield hospitals:

“We are a world-leading transcatheter MitralClip service. We are the most experienced unit in the country by a long way. We have now completed more than 250 MitraClip procedures.

A patient requiring treatment is not just getting me as a consultant – they’re getting a whole team. I work closely in a highly skilled team with surgeons, cardiologists, anaesthetists and nurses.”

One of those nurses is clinical nurse specialist, Lauren Connolly, who second operates with Dr Smith. Lauren coordinates all MitraClip patients, by liaising with them in the run-up to the procedure. The open nature of communication means that patients are fully prepared for their procedure and they understand what is going on.

Dr Smith’s team are continually pushing the boundaries, in addition to MitraClip the team are undertaking many new and innovative transcatheter procedures to treat both mitral and tricuspid valve disease.

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