Mitral Valve Replacement after Failed MitraClip™ Therapy - should we Reconsider Indications?

Objectives: Transkatheter mitral valve repair (MitraClip™, Abbott Vascular, Santa Clara, CA, USA) is more and more accepted as a suitable therapy for high risk patients with severe mitral regurgitation. However, it still remains unclear whether there is a significant number of patients which could be treated by conventional mitral surgery with comparable risks and potentially better functional results.

Methods: We report about two patients who successfully underwent surgical treatment of remaining mitral valve regurgitation after interventional treatment with MitraClip.

The first multimorbid patient (male, 66 years old, logistic Euroscore 30%) received a MitraClip™ therapy due to poor left heart function (Ejection fraction, 15%) with ischemic mitral regurgitation grade III-IV . Unfortunately, severe mitral regurgitation remained after the MitraClip™ treatment and valve replacement was unavoidable.

The second patient (male, 52 years old, logistic Euroscore 40%) was admitted with symptomatic mitral regurgitation grade III caused by endocarditis, which occurred 3 years after an initially successful MitraClip™ treatment. As in prosthetic valve infection surgery was the only appropriate therapeutic option.

Results: Mitral repair was not possible in both patients due to severe leaflet destruction. Therefore both patients received a biological mitral valve replacement and closure of the iatrogenic atrioseptal defect via sternotomy. The first patient was extubated and inotropes were weaned on the first postoperative day. The postoperative course was uneventful and he was discharged from our department on the 11th postoperative day.

The second patient received concomitant tricuspid valve repair and pacemaker lead removal. His post-operative course was prolonged due to pneumonia. He was finally extubated on the 16th postoperative day and discharged from hospital on the 52nd postoperative day.

Conclusion: Straight forward mitral valve surgery, in the hands of experienced surgeons, might be a reasonable option even for patients considered to be candidates for interventional mitral valve clipping. Our case report shows that the conventional operation can be successfully performed even in urgent and re-intervention cases. This suggests that the primary decision for surgery might have been the better choice in these patients and that a reasonable chance of valve reconstruction has been missed.