Transcatheter treatment of mitral valve regurgitation is obviously effective. It is a minimally invasive treatment method for mitral valve prolapse. Percutaneous transcatheter heart valve treatment is especially important for patients who might not be able to tolerate open-heart surgery. For example, in very elderly patients, how do you select patients for transcatheter treatment of mitral valve regurgitation, with regards to their age and their functional status?

For so as you know, age is not the only measure. Age is, first of all, [relative]. There is a biological age. That is age on a passport. So age is not the main reason to make decisions. But for sure, there are many considerations when it comes to age. In a younger patient, which is very common in the degenerative mitral regurgitation, in Barlow's mitral valve disease, patients below 60 years of age. Then, yeah, I would not so easily propose an endovascular procedure to repair a mitral valve because I know that in these cases, I can provide a surgical approach. A scar is almost invisible because today, we really do periareolar or submammary incisions. You don't see anything at the end. And we perform a procedure that includes mitral valve leaflet repair and mitral valve annulus repair at the same time. If there is a need to treat the tricuspid valve, it can be done simultaneously. So it is a complete solution, eventually, even with treating atrial fibrillation. When you go beyond 60or 65 years of age, let's say beyond 70 years of age, I start thinking this. Even if the patient has no comorbidities, I start having some doubts. It's not easy to make a decision. The beauty of endovascular transcatheter mitral valve repair is that the patient can go home within days after the procedure. And the results have not been at all bad. I mean, we have great results in most of our patients. So in the very elderly also, I have no doubts. I offer endovascular mitral valve repair. At a very young, I offer surgical methods of mitral valve repair. For situations in the middle, I make decisions with patients. I will tell them the advantages and disadvantages of the two procedures. I try to drive them through this decision-making. And at the end, we take a shared decision. What is fundamental in my practice, if we go for endovascular mitral valve repair, let's say, in a 65-years-old patient, would really doesn't want to have open-heart surgery. I will really discuss a lot with this patient to convince them that surgery is better. But maybe really, the patient doesn't want to have surgical mitral valve repair. Or there are some doubts because a patient has some comorbidities. I am very clear with the patient that we do endovascular mitral valve repair, usually edge-to-edge mitral valve repair. If it doesn't work, then within weeks, the patient needs to be operated on. So that we can still repair the mitral valve, and I take care of that too. And I know that I can repair the mitral valve because there is this idea that after MitraClip, you cannot repair the mitral valve surgically. This is not true unless there has been a disruption of the mitral valve or unless you wait for six months after the transcatheter procedure when you have a healing process. If you open it immediately, you see on most occasions. You see immediately that the transcatheter procedure didn't go well. If you see these patients with failed transcatheter mitral valve repair, they need to be operated on immediately.

So, what are the factors that can predict the success or the failure of mitral valve regurgitation treatment by transcatheter methods?

This is also a moving target because we started in the year 2005 with the Everest criteria. They are still today pretty valid, you know. Everest criteria include narrow lesion, single lesion, central lesion, with not much gap in between the leaflets. This is the ideal condition. There are several subcategories and details. When you develop your practice, you really find fine details, which may predict the success or failure of the procedure. Today we have updated algorithms for patient selection [for mitral valve repair method]. But imagine that just a few months ago, our portfolio of devices is being improved. So we are still learning.

When we developed the Everest criteria, there was only one size clip for mitral valve repair. Now we have four sizes of MitraClip, and we have larger and longer MitraClip. And we also have Pascal. That is another device for transcatheter mitral valve repair. It is a clasp plus a filler in between. So there are different devices. There will be another device soon coming from Asia. It's difficult today to give a final judgment on the method of heart valve repair. I think it very much depends on the expertise of the operator. I can more or less identify those patients who are high risk for me. I think there are some patients where I really discussed open heart surgery. A patient can have a bileaflet mitral valve disease with multiple jets of mitral regurgitation. This is a condition where you do not always get good results [with MitraClip]. When you have deep clefts in the valve, we can treat them [endovascularly]. But still, sometimes there are problems in these patients. When you see calcified annulus and very thin leaflets, it may be another risk factor in a patient. So there are some patients where I step back, or at least I warn the patient that there might be a less than optimal outcome. Other than that, I have to say that almost every patient can be treated with these transcatheter technologies. If there is no calcium, on most occasions, we can improve mitral regurgitation by transcatheter repair methods.