Clinical Impact of Multiple‐Clip Implantation for Residual Mitral Regurgitation After Transcatheter Edge‐to‐Edge Repair

Background Residual moderate or greater mitral regurgitation (MR) after transcatheter edge‐to‐edge repair is strongly associated with adverse clinical outcomes. However, the prognostic impact of implanting additional clips in patients with significant residual MR after the first clip remains uncertain. We evaluated the clinical and echocardiographic outcomes of multiple‐clip implantation for significant residual MR following placement of the initial clip. Methods We retrospectively evaluated 826 patients with moderate or greater residual MR on intraprocedural transesophageal echocardiography after placement of the first clip during transcatheter edge‐to‐edge repair at the Cedars‐Sinai Medical Center from 2014 to 2023. Patients were categorized into single‐clip (n=113) and multiple‐clip (n=713) groups. The primary end point was the composite of all‐cause mortality and heart failure hospitalization at 1 year. Results Procedural technical success and complication rates were comparable between groups. The multiple‐clip group demonstrated greater MR reduction and higher transmitral pressure gradients at discharge, 30 days, and 1 year. At 1 year, the composite end point occurred less frequently in the multiple‐clip group than in the single‐clip group (16.8% versus 29.2%; P =0.002), along with greater and more sustained improvement in New York Heart Association functional class. In subgroup analyses, multiple‐clip implantation consistently reduced major adverse cardiovascular events in patients with moderate as well as moderate–severe/severe residual MR. Conclusions In patients with significant residual MR after implanting the first clip, multiple‐clip implantation improved MR reduction and 1‐year outcomes without increasing complications. Even in moderate residual MR, additional clips were associated with more favorable clinical outcomes.