MitraClip: a word of caution regarding an all too liberal indication and delayed referral to surgery in case of failure

Abstract

OBJECTIVES Although indications for the MitraClip are becoming increasingly liberal, the number of patients requiring valve surgery after an insufficient outcome of the procedure is growing. Referral to surgery is, however, frequently delayed. During this time, the patients often deteriorate. We retrospectively analysed patients before MitraClip implantation and after mitral valve surgery. METHODS A total of 49 patients who received a mitral valve replacement (average 8 ± 12 months after MitraClip implantation) were assessed. Of these, 53% had 2–4 clips inserted. The mean age was 73 years, and the mean log EuroSCORE was 20.79 ± 14.42%. Echocardiographic data obtained prior to MitraClip implantation and preoperatively, 10 days and 6 and 12 months after cardiac surgery were reviewed. Survival analysis, risk profile and postoperative complications were analysed. RESULTS The 30-day and 1-year mortality was 26.5% and 59.2%, respectively. Prior to MitraClip implantation, 42.8% of patients had mild tricuspid insufficiency and 6.1% had moderate tricuspid insufficiency. Prior to surgery, 26.5% showed mild, 32.7% moderate and 38.8% severe tricuspid insufficiency (P < 0.001). Furthermore, right heart function assessed by tricuspid annular plane systolic excursion deteriorated significantly after Implantation of the MitraClip (P < 0.001). In patients with a MitraClip, the pulmonary artery pressure was significantly higher at the time of mitral replacement than it was before the MitraClip was implanted (P < 0.001). CONCLUSIONS A subgroup of patients does not benefit from a MitraClip and shows progressive deterioration in cardiac function, making valve replacement under difficult circumstances inevitable. The earlier these patients are operated on, the better it is. It can be assumed that some patients would be better off with primary surgery, especially if mitral reconstruction is then still feasible. Therefore, the indications for MitraClip implantation should be carefully considered and caution should be exercised during monitoring.

Mitral valve surgery after failed transcatheter edge-to-edge repair

“…Despite the higher STS-PROM and frequency of prior cardiac operations, the 1-year mortality rate was 21%, which compares favorably with other reports in the literature, where 1-year mortality ranges from 26.5% to 41%. 9 , 15 , 17 The 1-year mortality observed in the current study is comparable to the 1-year mortality of 23.1% after isolated TEER. 3 These results suggest that mitral valve surgery following failed TEER is a viable option even in patients with previous cardiac surgery.…”

“…The rate of tricuspid valve repair was higher than in previous studies. 7 , 9 , 15 , 17 There is considerable controversy on the influence and benefit of tricuspid valve surgery at the time of mitral valve surgery. In the CUTTING-EDGE registry, severe tricuspid regurgitation was associated with increased 1-year mortality after mitral valve surgery for failed TEER, 9 but a recent Cardiothoracic Surgery Network trial showed no survival benefit when tricuspid repair was done during mitral repair surgery, with an increased rate of pacemaker implantation.…”

“…One-third of patients requiring surgery after TEER have a previous history of cardiac surgery, most commonly CABG. 7,[14][15][16] Half of our patients had a prior sternotomy. Whereas reoperations are more demanding and increase the overall risk, our outcomes are equivalent to primary operations following TEER failure.…”

Every day mitral valve reconstruction: What has changed over the last 15 years?

“…However, almost half of the patients are alive after 15 years. Mitral valve repair is one of the few remaining primary cardiosurgical procedures and it will remain in our hands as long as we are able to provide a reliable, stable and long-lasting anatomical repair surpassing the results of any interventional strategy [26][27][28][29][30]. Luckily, the complexity of the mitral valves plays into our cards in this regard.…”

Clinical Outcomes after Mitral Valve Surgery in Failed MitraClip Procedures

“…There are varying reports on the time frames between the MitraClip procedure and surgery: Mkalaluh et al 15 report median of 45 days and in-hospital mortality of 33.3%, Melillo et al 16 median of 330 days with an in-hospital mortality of 15% and overall mortality of 26.5%, and Ostovar et al 22 30 days' mortality 26.5% and 1-year mortality of 59.2%.…”