Mitral valve surgery after failed MitraClip—Operation for the inoperable?

Abstract

Background Percutaneous edge‐to‐edge mitral valve repair technique (MitraClip) is a widely used treatment for mitral regurgitation (MR) in patients assessed with high surgical risk or inoperability. Only limited experiences with this highest‐risk patient population exist. Procedural failure for MitraClip or recurrent MR is a strong predictor of 1‐year mortality. Open mitral valve surgery constitutes the last bailout for patients within this cohort. Methods This retrospective single‐center cohort study analyzed 17 mitral valve surgery patients after failed MitraClip. We, therefore, analyzed a high‐risk patient population (EuroSCORE II = 10 ± 2.0) with persistent mitral valve regurgitation, which was mainly caused by detachment or dislocation of the MitraClip. Results Symptomatic patients with failed MitraClip need a convenient operation (mean time to mitral valve surgery = 23 ± 44 days). The patient's collective showed many complex reoperations with the need for concomitant surgery. Considering the high‐risk patient population, we showed an average 30‐day all‐cause mortality (18%, n = 3) accompanied by typical postoperative complications related to prolonged mechanical ventilation (44 ± 48 h) and ICU stay (11 ± 11 days), reflecting high‐risk patients. Further, excellent valve‐related outcomes were shown regarding adverse cardiac events (valve‐related mortality 6%, n = 1) and postoperative echocardiographic results (moderate or severe paravalvular leak 6%, n = 1). Conclusion Failure of MitraClip represents a challenging situation limited by high‐risk profiles of patients and limits the possibility of surgical valve repair, shown by a high rate of mitral valve replacement (94%, n = 16). Secondary surgery was associated with moderate 30‐day and postdischarge outcomes. Therefore, a careful evaluation of patients undergoing MitraClip is of paramount importance.

Were they inoperable? Really?

“…One other important consideration is the fact that use of the MitraClip generally limits the possibility of subsequent surgical valve repair, shown by Gerfen and colleagues' 6 high rate (94%) of mitral valve replacement, that confirms other authors’ experience 7 . That's why valves amenable to surgical repair, should have had that option considered initially.…”

“…4,5 Which raises the question of subsequent surgery in the cases of early or late clip failure, especially in emergency situations, that is, an "operation for the inoperable." This is precisely the subtitle of a paper published in this issue of the Journal by Gerfen and colleagues from Cologne, Germany, 6 in which the authors describe a retrospective single-center cohort study of 17 patients requiring mitral valve surgery after failure of the MitraClip procedure. This series is constituted by a high-risk (mean EuroSCORE II = 10), very symptomatic patient population with persistent or severe recurrent mitral valve regurgitation, which was mainly caused by detachment or dislocation of the clip.…”

Surgical outcomes of patients at prohibitive risk who are reconsidered for surgery

“… 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 However, some patients will be ineligible for a transcatheter intervention, usually due to anatomic factors. 14 , 15 At this time, the valve team must decide between medical management or prohibitive-risk surgery.…”

“…A series of patients at prohibitive risk who underwent surgery after failed transcatheter approach had extremely poor outcomes postoperatively with high morbidity and mortality, supporting that patients at prohibitive risk should only be offered surgery as a last resort or salvage procedure. 14 , 15 However, this was a patient population that had already been selected for a transcatheter intervention where surgery was being performed as an emergency bailout approach—a timing of surgery that is known to portend worse outcomes—and thus not our population of interest for patients at prohibitive risk deciding between medical management and surgery. 14 , 15 Another group examined outcomes of patients at prohibitive risk who were ineligible for transcatheter therapies, which showed acceptable immediate postoperative outcomes.…”

“… 14 , 15 However, this was a patient population that had already been selected for a transcatheter intervention where surgery was being performed as an emergency bailout approach—a timing of surgery that is known to portend worse outcomes—and thus not our population of interest for patients at prohibitive risk deciding between medical management and surgery. 14 , 15 Another group examined outcomes of patients at prohibitive risk who were ineligible for transcatheter therapies, which showed acceptable immediate postoperative outcomes. 16 However, the only inclusion criterion for prohibitive risk was older than age 80 years and did not include other accepted prohibitive risk criterion such as predicted risk of mortality (PROM) >8%, hostile chest, immobility, or frailty.…”