Treating Mitral Valve Regurgitation Without Open-Heart Surgery

What is mitral valve regurgitation?

The heart is a living pump, and the valves help to regulate the flow of blood in one direction through the heart, ensuring adequate flow to the rest of the body.

Mitral valve regurgitation occurs when the mitral valve does not close properly; this means that instead of forward flow, some blood flows backwards when the heart pumps. As a result, the heart needs to work harder to distribute blood throughout the body, creating unnecessary strain.

What are the symptoms of mitral valve regurgitation and how does it affect patients?

Experiences vary based on the severity of the condition. Common symptoms include:

• Shortness of breath, especially during exertion or when lying down
• Palpitations, or irregular heartbeat
• Swelling of the abdomen, ankles or feet (known as oedema)
• Chest discomfort
• Heart murmur
• Fatigue, especially when active

How is it diagnosed?

Mitral valve regurgitation is diagnosed with a physical exam and with the help of some tests. To begin, the doctor will use a stethoscope to listen to the patient’s heart, looking for unusual sounds, or a heart murmur. If further investigation is needed, the doctor may recommend diagnostic tests. These may include an echocardiogram, coronary angiogram (also known as cardiac catheterisation), or electrocardiogram (ECG).

What are the treatment options?

Conventional options include medication, or open-heart surgery to repair or replace the valve. The doctor’s recommendation is based on the severity of the condition, the state of the patient’s health and the presence of other abnormalities in the heart.

The aim of treatment is to reduce the severity of mitral regurgitation, thereby helping to restore optimal blood flow and relieving symptoms. This helps improve a patient’s quality of life.

For patients who are not ideal candidates for open-heart surgery, or want to avoid it, transcatheter edge-to-edge repair (TEER) has emerged as a safer, less invasive alternative.

What is transcatheter edge-to-edge repair (TEER)?

This is a minimally invasive procedure used to treat mitral valve regurgitation by clipping together the leaky valve leaflets to reduce the backward flow of blood.

At Mount Elizabeth, two advanced TEER systems are available:

• MitraClip

With MitraClip, the cardiologist uses a delivery system to guide and position the clip at the site of the leak. The clip brings the leaflets together, allowing the valve to close more effectively and reduce regurgitation. More than one clip may be used if necessary.

• PASCAL

The PASCAL system works in a similar way but includes design features that may provide greater flexibility and reduce tension on the valve leaflets. It also has a central spacer component to help fill the regurgitant orifice, potentially improving outcomes in certain valve anatomies.

Your heart team will assess which system is most appropriate based on your condition and anatomy.

How does TEER work?

During the TEER procedure, a catheter is inserted through a small needle puncture in the femoral vein in the leg and guided to the heart. Using real-time echocardiography and X-ray guidance, a small clip-like device is positioned across the leaky mitral valve. This device grasps and holds together the valve leaflets at the site of leakage, enabling the valve to close more effectively and reducing the regurgitation. The procedure is typically done under general anesthesia and allows patients to recover more quickly compared to open-heart surgery.

What are the benefits of TEER devices like MitraClip and PASCAL?

TEER devices such as MitraClip and PASCAL offer a minimally invasive alternative to open-heart surgery, particularly for patients who are considered high-risk surgical candidates.

With MitraClip, extensive global experience and research have shown sustained benefits. As of March 2019, more than 80,000 patients worldwide had been treated with MitraClip, and over 17,000 of them were followed through studies and clinical registries. These long-term data demonstrated improvements in heart function, symptoms, and quality of life — including better exercise tolerance and a significant reduction in hospital admissions for heart failure. Many patients also experienced continued benefits up to 5 years after the procedure.

The PASCAL system, a newer generation TEER device, brings several unique design advantages. It includes a central spacer that fills the regurgitant gap between valve leaflets, potentially reducing stress on the tissue and achieving a more complete seal. Its broad paddles and flexible clasping mechanism also allow for independent leaflet grasping, offering greater control and suitability for complex valve anatomies.

Both TEER systems offer:

• Faster recovery times
• Less post-procedural pain
• Improved ability to carry out daily activities
• Reduced risk of complications compared to open surgery
• Shorter hospital stays and fewer readmissions for heart failure

These benefits can make a meaningful difference in the lives of patients, helping them regain independence and improve their overall wellbeing.

What are the risks of TEER?

Any type of procedure, even one that is minimally invasive, poses risks.

Among those associated with MitraClip are small risks of infection at the entry site, damage to blood vessels and/or cardiac structures, bleeding and the development of a clot or air bubble, which can lead to stroke. The risks of device migration are uncommon. Occasionally, an inter-atrial communication may persist which requires a separate procedure to close this.

Who is suitable/eligible to undergo the MitraClip procedure?

Approved indications for TEER systems such as MitraClip and PASCAL around the world may differ.

In Singapore, patients with more than moderate to severe mitral valve regurgitation may be considered for TEER, especially if they are considered high-risk for open-heart surgery.

Examples of those most suited for TEER are those whose physical condition or pre-existing chronic disease/s would make open surgery too risky.

Unsuitable candidates include those who are at high risk of bleeding and those unable to tolerate the blood thinning medicines required for the procedure; patients with active infection of the mitral valve; patients with severe stenotic rheumatic heart disease; those who have a blood clot within the heart chamber or the blood vessels through which the TEER needs to be delivered.

Each individual patient must be carefully reviewed by cardiologists and/or cardiac surgeons experienced in the TEER procedure to determine their suitability. 

Speak to our cardiologists about your condition to have your concerns addressed before deciding if TEER is right for you.