Outcome of medical therapy, repeat intervention, and mitral valve surgery after failed MitraClip therapy

Optimal treatment for residual mitral regurgitation (MR) after MitraClip failure is not clearly defined. We report our clinical experience and discuss treatment options.

Between January 2013 and January 2018, 37 patients (75 ± 8.9 years, 46% male) were admitted for symptomatic MR (grade 3.1 ± 0.47) diagnosed after previous MitraClip therapy. Clinical outcome of these patients, who underwent medical therapy alone (n = 8, M-group), repeat MitraClip therapy (n = 8, reMC group), or mitral valve surgery (n = 21, S-group) for residual MR, were retrospectively analyzed.

Thirty-day survival was 88% (M-group), 100% (reMC-group), and 76% (S-group). The rate of discharge to home was 88% in the reMC-group, better than 38% in the M-group (p = 0.051) and 19% in the S-group (p < 0.001). Perioperative non-survivors in the S-group had high surgical risk with median logistic EuroSCORE of 64.6% (interquartile range 57.4%-87.0%); all died from low cardiac output syndrome or multiple organ failure. The main MR pathologies resulted from leaflet tear and tethering in the M-group, tethering in the reMC-group, and degenerative valve and leaflet tear in the S-group. Kaplan-Meier analysis of overall survival at 1 year showed better outcome for patients in the reMC-group (50%, 95% CI 15.2-77.5%) and S-group (47.6%, 95% CI 25.7-66.7%), as compared to those in the M-group (12.5%, 95% CI 0.70-42.3%) (log-rank test p = 0.108 and p = 0.167, respectively).

Medical therapy alone after failed MitraClip therapy resulted in poor 1-year prognosis. In patients without extremely high surgical risk, repeat MitraClip therapy, or surgical revision MIGHT BE CONSIDERED depending on valve pathology and cardiac comorbidities.