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.

The Effect of Concomitant Tricuspid Valve Regurgitation on the Condition of Patients with Ischemic Mitral Insufficiency

Ischemic mitral regurgitation is one of the most difficult and complex problems of surgical treatment of coronary heart disease and drug therapy of this group of patients. Mitral regurgitation in coronary heart disease negatively affects the survival of patients. The combination of ischemic mitral regurgitation and tricuspid valve insufficiency significantly worsens the prognosis in this category of patients. The aim. To study the effect of concomitant tricuspid insufficiency on the condition of patients with ischemic mitral regurgitation. Material and methods. From January 2012 to December 2019, 292 patients with ischemic mitral insufficiency underwent surgical intervention at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine. Results and discussion. Almost half of the patients (48.0%) who applied to the Institute and had severe tricuspid valve regurgitation already had a history of moderate right atrial hypertrophy. In the expressed backflow on the tricuspid valve these blockades occur much more often than in the absence of insufficiency of the tricuspid valve (p<0.01). The occurrence of ventricular and atrial extrasystoles is also not reliably linked to the level of tricuspid valve regurgitation. Examining the results of surgical treatment of patients with mitral regurgitation of ischemic origin revealed positive correlation between the effect of tricuspid valve regurgitation and postoperative mortality. Examining the results of surgical treatment of patients with mitral regurgitation of ischemic origin revealed positive correlation between the effect of tricuspid valve regurgitation and postoperative mortality. Conclusions. Concomitant tricuspid insufficiency in mitral regurgitation of ischemic origin significantly affects clinical condition of patients and their quality of life. The results of surgical treatment of patients with ischemic mitral regurgitation also depend on the degree of preoperative tricuspid valve regurgitation.