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

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.