Thread by @dr_benoy_n_shah

#EACTS2021

This is a 🧵all about Transcatheter Mitral Valve Implantation (TMVI). If you don't know a lot about this and want to learn more - read on! This is a summary of a great expert focus session

First talk from Dr Gry Dahle (Oslo), on why TMVI is not the same as TAVI

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1st TAVI was done 10 years before 1st TMVI

TAVI has revolutionised treatment of aortic stenosis; TMVI is further behind largely due to anaromical complexity of treating the MV compared to the AV - the AV valves are much more complex than the semilunar valves!

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Historical timeline of the TMVI journey (left) and the large number of devices still competing for approval in the transcatheter mitral space (right)

@GilbertTangMD @mrjzacharias @BISMICS @SCTSUK @BrHeartValveSoc

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Last year, the #Tendyne system was the first to receive CE mark in Europe for TMVI

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Just like TAVI, pre-procedural imaging is vital for TMVI. However, unlike TAVI, much more detail is required around the valve anatomy & subvalvular apparatus, as well as LV size / shape, LVOT size etc

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OK, the echo talk was given by Royal Brompton stalwart @AlisonD61630805

A great overview for echo enthusiasts

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Lots of things to consider, including whether the patient is suitable initially for transcatheter edge-edge repair (TEER).

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Here, Alison explains the inclusion criteria for a Tendyne procedure. LV cannot be too big (<7cm) or too poor in function (EF >30% only) with no or minimal annular calcium

Predominantly for primary MR patients unsuitable for surgery or TEER
Can be used in 2o MR also

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Initial TTE important to look at anatomy and physiology, paying special attention to RV size and function also

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3D-TOE of course allows for even better assessment of the MV, including checking for presence of clefts and confirming exact scallop pathology

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Need to ensure the MV annulus is neither too large nor too small

Measure using biplane view on TOE in end-systole

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Then, the pre-procedural CT talk from Dr Bhadra

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Patients may be deemed unsuitable for TMVI due to imaging considerations, either by echo or CT or both

Some examples of why patients had suffered screen failures in their centre were shared here

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Next, a specific talk on the Tendyne system from Dr David Muller in Australia

Started by explaning what the Tendyne system is: the apical pad helps not just anchor the device and provide stability but also with haemostasis

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This is the appearance of the device on echo once deployed on 3D (left) and 2D imaging (right) with laminar flow across the valve

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Next, data from the Tendyne CE mark study. 191 patients

Mean age 74
Mean STS score 7.7%
Mean LVEF 44%
~70% NYHA Class III / IV HF
88% had 2o MR
Lots of co-morbidity

30-day mortality ~8%
90-day mortality ~16%

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On-going SUMMIT trial will evaluate relative roles of both TEER and Tendyne system

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Next talk on the Tiara device, by Prof Anson Cheung from Vancouver

Tiara is a transapical valve that comes in 2 sizes (35mm & 40mm) and has anchors that aim to capture the native AMVL, reducing risk of SAM and LVOTO

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TIARA I was the early feasibility study, now on to TIARA II

Recruitment hampered significantly by COVID-19, hence only 83 implants to date

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Here are the demographic and echocardiographic data from the trials

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Tiara outcomes here. No immediate procedural mortality. Successful deployment & correct position in 93% cases. Overall short-term outcomes show promise

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Conclusion slide - the longest survivor is already >7 years out from surgery!

Will be interesting to see how this fares in the future against Tendyne, which has 10 times as many implants worldwide so far. Is there room for both systems? Probably...

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Next talk from @m_taramasso on TMVI in 2 special situations:

1. Mitral annular calcification (MAC)
2. Previous SAVR / TAVI procedure

Started by reminding us that valve-in-MAC is not good, not bad but ugly!

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Valve-in-MAC has a worse outcome than valve-in-ring and valve-in-valve...why?

Up to 40% can develop LVOTO...that will be a major factor

I reached the end of a thread!

Final tweet in this thread - data of n=11 from Tendyne system in MAC shows some promise...and prior AVR/TAVI should not be considered a contra-I to TMVI

See you all tomorrow!

#EACTS2021 @EACTS @rafasadaba