When is a Mitraclip recommended for patients with mitral regurgitation?

MitraClip Recommendations for Mitral Regurgitation

MitraClip is recommended for patients with severe (3+ or 4+) primary degenerative mitral regurgitation who are at prohibitive surgical risk, and for patients with severe secondary mitral regurgitation who remain symptomatic despite optimal medical therapy with LVEF 20-50% and LV end-systolic diameter <70 mm. 1

Indications Based on Type of Mitral Regurgitation

Primary (Degenerative) Mitral Regurgitation

• First-line therapy: Surgical mitral valve repair remains the gold standard for severe primary MR 1
• MitraClip indications:
  • Symptomatic patients (NYHA class III-IV) with severe MR
  • Prohibitive or high surgical risk
  • Life expectancy greater than 1 year
  • Favorable valve anatomy for clip placement 1

Secondary (Functional) Mitral Regurgitation

• First-line therapy: Optimal guideline-directed medical therapy (GDMT), including revascularization and cardiac resynchronization therapy if indicated 1
• MitraClip indications:
  • Persistent severe MR (3+ or 4+) despite optimal GDMT
  • LVEF between 20-50%
  • LV end-systolic diameter <70 mm
  • Symptomatic despite medical optimization 1

Anatomical Criteria for MitraClip Eligibility

Favorable Anatomical Features

• Noncommissural pathology (medial, middle, lateral segments)
• Minimal or no calcification in grasping zone
• Mean mitral valve gradient <4 mmHg
• Mitral valve area ≥4.0 cm²
• Grasping zone length >10 mm 1

For Primary MR Specifically

• Flail width <15 mm
• Flail gap <10 mm
• Single segment pathology
• Normal leaflet thickness 1

For Secondary MR Specifically

• Coaptation depth <11 mm
• Coaptation length ≥2 mm 1

Contraindications for MitraClip

• Rheumatic mitral valve disease
• Severe leaflet or annular calcification
• Leaflet restriction in both systole and diastole (Carpentier IIIA)
• Mitral valve area <4.0 cm² (risk of causing mitral stenosis)
• Flail width >15 mm or flail gap >10 mm
• Highly mobile flail leaflet with multiple ruptured chords
• LVESD >70 mm in secondary MR 1

Procedural Outcomes and Considerations

• Acute procedural success rates of approximately 89-96% 2, 3
• Most patients (approximately 70%) require only a single clip 3
• 30-day survival rates of 97-98% 2
• 12-month survival rates of approximately 82% 2
• Low rate of mitral valve re-intervention at 12 months (approximately 3%) 2
• Significant improvement in NYHA functional class (90% of patients show clinical improvement at discharge) 3

Important Clinical Considerations

• MitraClip is less effective than surgical repair for reducing MR but has faster recovery times and less bleeding 1
• The dynamic nature of secondary MR means patients should be on optimal medical therapy before determining MR severity 1
• Echocardiographic guidance is critical for both patient selection and procedural success 1
• Transoesophageal echocardiography (TOE) is essential for pre-procedural evaluation and guiding the procedure 1

Decision-Making Algorithm

1. Assess MR severity: Integrate multiple parameters (EROA, regurgitant volume, vena contracta)
2. Determine MR etiology: Primary vs. secondary
3. Evaluate surgical risk: Using STS score or EuroSCORE
4. For primary MR:
   • If surgical candidate → Surgical repair
   • If prohibitive surgical risk → Consider MitraClip
5. For secondary MR:
   • Optimize medical therapy first
   • If symptoms persist with LVEF 20-50% and LVESD <70 mm → Consider MitraClip
6. Assess anatomical suitability: Using echocardiography criteria
7. Heart Team discussion: Multidisciplinary evaluation for final decision

The MitraClip procedure has expanded treatment options for patients with severe MR who previously had limited therapeutic alternatives, particularly those at high surgical risk, demonstrating significant improvements in quality of life and functional capacity.