MitraClip implantation followed by insertion of a left ventricular assist device in patients with advanced heart failure

Abstract

Aims Mitral valve regurgitation (MR) is common in patients with advanced heart failure (HF). Percutaneous mitral valve repair (PMVR) via MitraClip (MC) has emerged as a feasible treatment strategy for these high-risk patients. However, as HF often further progresses, there is a frequent need for left ventricular assist device (LVAD) implantation in these patients. We aimed to investigate whether prior MC implantation affects the subsequent LVAD implantation and outcome. Methods and results Thirty-seven patients with advanced HF and significant MR who underwent LVAD implantation were retrospectively analysed. Follow-up data were collected at 1 year after LVAD implantation. Primary endpoint was all-cause mortality. Secondary endpoint included peri-operative parameters and clinical development depicted as New York Heart Association (NYHA) class and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level. Seventeen patients initially received a MC device (MC group), resulting in a significant reduction in MR grade. After MC, NYHA class and INTERMACS level further worsened, leading to subsequent LVAD implantation after a median time of 475 days in the MC group. At LVAD implantation, overall characteristics were comparable with those of the patients undergoing LVAD implantation without prior MC placement (no-MC group). Procedural data revealed a higher incidence of right ventricular (RV) failure needing mechanical RV assistance and a longer need for nitric oxide ventilation in the MC group after LVAD implantation. One-year survival was slightly better in the no-MC group compared with the MC group [41% (n = 7/17) vs. 65% (n = 13/ 20); P = 0.15], albeit event-free survival was comparable between both groups, MC and no-MC. Conclusions LVAD implantation after MC is feasible and safe. However, in patients with advanced HF and severe MR, PMVR may only delay a needed LVAD implantation and thereby lead to poorer peri-operative RV function and impaired outcome. Arguably, these patients might benefit from the timely management of advanced HF by the means of early LVAD implantation or heart transplantation.

Re‐do MitraClip in patients with functional mitral valve regurgitation and advanced heart failure

“… 17 , 18 , 34 This has to be even more taken into account when alternative treatment options such as permanent mechanical circulatory support are available, and patients with end‐stage HF may rather benefit from early implantation of a ventricular assist device, and prior PMVR may only delay this often unavoidable therapy. 35 In patients with advanced HF, PMVR certainly is a potential therapeutic option, but therapeutic strategies must be carefully evaluated. We believe that this is only possible in a specialized heart failure team, including heart failure cardiologists, interventional cardiologists, cardiac surgeons experienced in heart failure surgery, and colleagues from other disciplines such as anaesthesiology and nephrology.…”

“…Certainly, the procedure is more successful under optimized circumstances, and successful PMVR in advanced HF patient cohorts has been reported from many centres 17,18,34 . This has to be even more taken into account when alternative treatment options such as permanent mechanical circulatory support are available, and patients with end‐stage HF may rather benefit from early implantation of a ventricular assist device, and prior PMVR may only delay this often unavoidable therapy 35 . In patients with advanced HF, PMVR certainly is a potential therapeutic option, but therapeutic strategies must be carefully evaluated.…”

Impact of severe mitral regurgitation on postoperative outcome after durable left‐ventricular assist device implantation

“…There is an ongoing debate regarding the interventions on the mitral valve in heart‐failure patients, which remains controversial and sometimes inconclusive 16,17 . The main goal of these interventions is to reduce the risk of developing heart failure, which is known to be associated with increased mortality in LVAD patients 18 .…”

“…There is an ongoing debate regarding the interventions on the mitral valve in heart-failure patients, which remains controversial and sometimes inconclusive. 16,17 The main goal of these interventions is to reduce the risk of developing heart failure, which is known to be associated with increased mortality in LVAD patients. 18 Even though, the current ISHLT guidelines do not recommend addressing the MR in patients undergoing durable LVAD implantation, it might be considered in patients presenting with concomitant moderate-to severe TR, in whom LVAD is implanted as destination therapy or as a bridge to recovery.…”

Commentary: Going deep by employing myocardial molecular biology for precision cardiac surgery

“…3,4 Considering the contribution of MR to right heart failure while supported by LVAD therapy, some believe that mitral valve repair should be performed concomitant to LVAD implantation. 5 As surgeons know well, MR is sometimes cause and sometimes consequence. It is often a symptom of the underlying disease, particularly for patients with advanced end-stage HF.…”