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MitraClip: an innovation for mitral regurgitation

Abbott Vascular International
29 May, 2014  
MitraClip, the percutaneous mitral valve repair system from Abbott Vascular, is expanding treatment options for patients with significant mitral regurgitation
 
This content is provided by
Abbott Vascular International
 
In a normally functioning mitral valve, blood flows in a single direction from the left atrium to the left ventricle. Mitral regurgitation (MR) results from a lack of leaflet coaptation between the two leaflets of the mitral valve during the ventricular contraction. As a consequence, part of the ejected blood volume regurgitates to the left atrium. MR occurs when the mitral valve (for example, the leaflets), or one or more of the supporting structures, becomes damaged or dysfunctional. To learn more on MR, visit www.knowmoremr.com.
 
Moderate-to-severe MR is associated with an increased mortality: Estimates for one-year mortality among patients with severe MR range from 7.3% to 57%.(1) MR progresses to heart failure (HF) and affects about one in ten people aged over 75 years.(2)
 
MR is the most common type of heart valve insufficiency in the US:(2) 
1.7% of US adults (adjusted to year 2000 population) are estimated to have at least moderate MR
Prevalence increases with age, from 0.5% for 18–44-year-olds rising to 9.3% for ≥75-year-olds (p<0.0001). 
 
MitraClip: from concept to therapy
Inspired by the Alfieri surgical edge-to-edge technique for mitral valve repair, the MitraClip system is the first-of-its-kind percutaneous mitral valve repair system for the treatment of moderate-to-severe or severe MR.
 
The MitraClip device received a CE Mark in 2008. In 2011, results from the landmark EVEREST II randomised control trial were published(3) and, recently, the five-year-results were presented at ACC 2014 demonstrating durability of the Therapy’s outcomes. In 2012, MitraClip was included in the 2012 European Society of Cardiology (ESC) guidelines on management of valvular heart disease, indicating that the percutaneous edge-to-edge procedure may be considered in high-risk MR patients fulfilling the echo criteria for eligibility. 
 
The system
MitraClip is utilised during a percutaneous repair procedure (as opposed to open heart surgery offered by conventional surgery). The system allows physicians to conduct real-time MR assessment in the beating heart and to reposition the device multiple times until the desired reduction in MR is obtained.
 
The procedure
  • While the patient is under general anaesthesia, the clip is introduced percutaneously into the body through the femoral vein followed by trans-septal access to the mitral valve
  • Mitral valve leaflets are grasped and coapted, resulting in a double orifice valve
  • MR reduction is assessed with real-time trans-oesophageal echocardiography (two- or three-dimensional) to obtain optimal outcome
  • The procedure neither requires arresting the heart nor cardiopulmonary bypass.
What are the patient profiles?
  • The MitraClip procedure has the potential to be a valid treatment option for selected patients with significant MR. In particular, based on the current evidence, high-risk symptomatic, or otherwise inoperable patients with severe MR (organic or functional), seem the best candidates for the MitraClip, whenever the echocardiographic criteria of eligibility are met(4) 
  • Patient screening and selection are essential to the success of the procedure. 
A multidisciplinary approach
Abbott Vascular is committed to a multidisciplinary approach in order to optimise the quality of care and to support heart teams:
  • A two-day training course followed by onsite support and expertise sharing from European centres of excellence are offered to the implanting team before the start-up of the program in their institution
  • The heart team comprises:
–  Interventional cardiologist and/or cardiac surgeon (primary or secondary operator)
Echocardiologist (carrying out trans-oesophageal echocardiography for screening and during the procedure)
–  Anaesthetist (patient monitoring during the procedure) 
–  Cath lab technician/nurse (case support) 
  • To capitalise on the initial training and the learning curve of the team,(5) and to try to maintain safety and therapeutic effectiveness, a minimum of two-to-three procedures per month is recommended
  • Procedures are supported by experienced proctors.
An increasing body of clinical evidence
At present, more than 13,000 patients(6) have been treated with the MitraClip system worldwide and the body of clinical data and published articles (>360) continues to grow.
 
One-year follow-up results from ACCESS EU – real world registry in Europe on 567 patients – were published by Maisano et al.(7) More than half the patients in ACCESS-EU had an ejection fraction <40%, and 85% had NYHA class III or IV. Positive outcomes have been reported in multiple published registries (TRAMI(8) for Germany, GRASP(9) for Italy) and cohorts. A critical observation from the real world registries was a shift from the EVEREST II patient population of primarily degenerative, surgical candidates toward mostly functional (77%), high surgical risk patients.
 
Several European implanters have published results(10–12) in patients with end-stage systolic HF, and high STS and EuroSCORE. Their preliminary results with MitraClip system demonstrate significant reductions in MR, improvements in NYHA functional class, 6-minutes-walk tests and pro-BNP levels.
Abbott Vascular is committed to pursuing the development of strong evidence demonstrating further the value of the therapy and supporting reimbursement efforts. 
 
Economic value of MitraClip
MR is often associated with HF, which is one of the most common cardiovascular disorders worldwide and poses a significant economic burden.(13) In the US, the estimated annual cost of HF in 2010 was $39.2 billion or ~2% of the total US healthcare budget. The main cost drivers of HF are hospitalisation, nursing home care, home health care and medications.
 
Hospitalisations account for about 60% of total HF costs in the US. Current therapeutic options include medical management, surgical repair or replacement and percutaneous interventions.
 
Low hospital length of stay
A significant reduction in the postprocedural hospital length of stay has been shown in the EVEREST II RCT. The average length of stay for the MitraClip group in the EVEREST randomised trial in surgical candidates was 2.6 days versus 7.5 days in the surgical control group. In the EVEREST II High Risk study, the average length of stay was three days for MitraClip patients. In the European ACCESS-EU cohort, the reported average length of stay was 7.7 days.(6,7)
 
Recipients of MitraClip are less likely to require home care or nurse rehabilitation post valve repair as home discharge is indicated in most cases (cf. Impact on discharge [at 
lower right]).
 
A preliminary economic model (a ten-year UK-based cost-utility analysis) shows that MitraClip is a cost-effective treatment option at five years for individuals with MR who are currently ineligible for surgical repair or replacement.(14)
 
Currently, the MitraClip is available for use in more than 20 countries in Europe, Middle-East and Africa, as well Australia, Asia and Canada. Reimbursement has been obtained in several countries, as, for example, in Germany where MitraClip is covered through DRG F98C (Complex Mini-invasive Heart Valve procedures), Switzerland, The Netherlands and Turkey.
 
References
  1. Cioffi G et al. Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure. Eur J Heart Fail 2005;7(7):1112–7.
  2. American Heart Association. Heart disease and stroke statistics. Dallas, TX; 2003.
  3. Feldman T et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011;364:1395–406.
  4. van den Heuvel A, Alfieri O, Mariani M. MitraClip in end-stage heart failure: a realistic alternative to surgery? Eur J Heart Fail 2011;13:472–4.
  5. Schillinger W et al. Impact of the learning curve on outcomes after percutaneous mitral valve repair with MitraClip and lessons learned after the first 75 consecutive patients? Eur J Heart Fail 2011;13(12):1331–9.
  6. Data on file: Abbott Vascular.
  7. Maisano F et al. Percutaneous mitral valve interventions in the real world: Early and one Year results from the ACCESS-EU, a prospective, multicenter, non-randomized post-approval study of the MitraClip® Therapy in Europe. JACC 2013;62(12):1052–61. 
  8. Schillinger W et al. Acute outcomes after MitraClip® therapy in highly aged patients: results from the German TRAnscatheter Mitral valve Interventions (TRAMI) Registry. EuroIntervention 2013;9:84–90.
  9. Grasso C et al. One- and twelve-month safety and efficacy outcomes of patients undergoing edge-to-edge percutaneous mitral valve repair (from the GRASP Registry). Am J Cardiol 2013;111:1482–7.
  10. Franzen O et al. MitraClip® therapy in patients with end-stage systolic heart failure. Eur J Heart Fail 2011;13(5):569–76.
  11. Pleger S et al. Acute safety and 30-day outcome after percutaneous edge-to-edge repair of mitral regurgitation in very high-risk patients, Am J Cardiol 2011;108(10):1478–82.
  12. Treede H et al. A heart team’s perspective on interventional mitral valve repair: percutaneous clip implantation as an important adjunct to a surgical mitral valve program for treatment of high-risk patients. J Thorac Cardiovasc Surg 2011;143(1):78–84. 
  13. Braunschweig F, Cowie MR, Auricchio A. What are the costs of heart failure? Europace 2011.
  14. Mealing S et al. EVEREST II high risk study based UK cost effectiveness analysis of MitraClip in patients with severe mitral regurgitation ineligible for conventional/replacement therapy. JME 2013;1–10.
 
MitraClip is a trademark of the Abbott Group of Companies. Product is subject to prior training requirement as per the Instruction for Use. This product is intended for use by or under the direction of a physician. Prior to use, it is important to read the package insert thoroughly for instructions for use, warnings and potential complications associated with the use of this device. Information contained herein is for distribution for Europe, Middle East and Africa ONLY. Please check with the regulatory status of the device before distribution in areas where CE marking is not the regulation in force. EVEREST II, ACCESS-EU and RESHAPE-HF are Abbott Vascular Sponsored Studies. All drawings are artist’s representations only and should not be considered as an engineering drawing or photograph. Photo(s) on file at Abbott Vascular. For more information, visit our web site at abbottvascular.com. 2014 Abbott. All rights reserved. 9-EH-1-3129-01 04-2014 REV A.