MitraClip™: What Should Not Be Done?

Introduction

We report the case of a patient with mitral regurgitation in whom MitraClip™ failed after initial surgical mitral repair. A second surgical intervention was needed to cure the patient definitively.

Treatment of mitral regurgitation remains challenging. Recently percutaneous treatment using the MitraClip™ has been proposed as an alternative to surgery with encouraging results [1]. However, MitraClip™ seems to be reserved for nonoperable patients as pointed out by recent data [2].

Case Report

A 59-year-old man was referred to our institution for dyspnea. He had a history of mitral valve regurgitation with posterior leaflet valve prolapse. In 2006 he underwent mitral repair without annuloplasty ring implantation. In April 2012 dyspnea, NYHA II–III, recurred. Echocardiography showed grade III to IV mitral regurgitation. He was referred to another hospital, where percutaneous treatment with MitraClip™ implantation was proposed to the patient. Two MitraClips™ were implanted. Shortly after the intervention the patient complained about shortness of breath. He was seen at our hospital. Transthoracic echocardiography (Figure 1) and cardiac computed tomography (Figure 2) confirmed the clinical impression of both mitral stenosis and regurgitation with significant gradient and a valve surface of 1.7 cm². M-mode echocardiography showed typical patterns of mitral stenosis (Figure 3). Mitral valve repair with annuloplasty could be performed with neocordals, reinforcement of the posterior leaflet and ring implantation (Figure 4 and Figure 5). Six months later, the mitral valve is fully functional and the patient is asymptomatic. This case is remarkable for a few points: firstly, mitral annuloplasty with ring implantation should be performed instead of simple repair. Secondly, equivalence of surgery with MitraClip™ implantation has been proven in some trials. However patients included in these studies were older and sicker than our patient. There are more arguments to suggest that MitraClip™ should be reserved for nonoperable patients or to patients refusing surgery. In our patient, revision surgery was probably a better option than a percutaneous approach. Valve dysfunction requiring a second intervention is almost 10 times more frequent after MitraClip™ implantation than after conventional surgery. Thirdly, even though trials about MitraClip™ are still ongoing, indications should not be lifted to younger patients, until we have clear evidence regarding the comparison of the 2 techniques. Finally, mitral valve repair with annuloplasty and ring implantation is possible after MitraClip™ implantation.