MitraClip Implantation: A Word of Caution Regarding an All Too Liberal Indication and Delayed Referral to Surgery in Case of Failure

Objectives: While indication for MitraClip is becoming more and more liberal, the number of patients requiring surgery after failed MitraClip is increasing. Transferal to surgery is, however, often delayed. During this time, the patients deteriorate. Depending on the number of implanted clips, there is often a moderate to severe mitral stenosis in addition to marked insufficiency. We analyzed the condition of the patients before MitraClip implantation retrospectively and surgical long-term (LT) outcome prospectively.

Methods: Short-term (ST) and LT outcomes of 40 patients who received mitral valve replacement on average 9 months ± 13 after MitraClip were assessed; 55% of the patients had two to four clips. Mean age was 72 years, mean log EuroSCORE was 22.11% ± 14.75. Echocardiographic data prior to MitraClip, preoperatively, as well as ST, midterm (MT), and LT after cardiac surgery were analyzed. Survival analysis, risk profile, and postoperative complications were analyzed. Statistical analysis was performed using SPSS19.0.

Results: The 30-day, 1-year, and LT mortalities were 22.5, 40, and 47.5%, respectively. Mean follow-up time of survivors was 44 months. While before MitraClip, 11 patients suffered from a mild tricuspid insufficiency (TI), 38 patients showed a moderate TI preoperatively (p = 0.003). Of these, 17 patients underwent tricuspid repair. Postoperatively, 20 patients showed a mild TI. Furthermore, right heart function assessed by TAPSE deteriorated significantly after MitraClip (p = 0.0006). In addition, preoperative pulmonary artery pressure was significantly higher than before MitraClip and after surgery (p < 0.001). Preoperative left ventricular ejection fraction (LVEF) was 43%, and postoperative ST, MT, and LT LVEFs were 43, 49, and 52%, respectively. There was a correlation between preoperative poor left or right ventricular function and mortality (p = 0.002, p < 0.001, respectively).

Conclusion: A subgroup of patients do not profit from MitraClip and exhibit progressive worsening of cardiac function so that valve replacement under challenging conditions is unavoidable. The earlier these patients are referred to surgery, the better is. It can further be speculated that some patients are better with primary surgery especially in view of the then maintained chance to reconstruct the valve. Indication for MitraClip should thus be considered carefully and alertness is necessary during surveillance.

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