What is the recommended follow-up care post mitral (mitral valve) clip procedure?

Recommended Follow-Up Care Post Mitral Clip Procedure

Echocardiographic follow-up at 6 months post-procedure is recommended for all patients who have undergone mitral clip placement to assess residual/recurrent mitral regurgitation and left ventricular remodeling. 1

Echocardiographic Assessment

Initial Follow-Up

• Transthoracic echocardiography (TTE) should be performed as the first-line imaging modality for routine follow-up, as it is typically sufficient for most patients 1
• A comprehensive assessment should include:
  • Evaluation of residual/recurrent mitral regurgitation 1
  • Assessment of left ventricular dimensions and volumes 1
  • Measurement of transmitral gradients to exclude mitral stenosis (mean gradient ≤5 mmHg is acceptable) 1

Assessment of Residual/Recurrent Mitral Regurgitation

• Color Doppler echocardiography using semi-quantitative techniques based on regurgitant jet dimensions is recommended 1
• Standard quantitative methods have limitations in the post-MitraClip setting:
  • PISA approach has not been validated for multiple jets or double orifice geometry 1
  • Mitral inflow volume needed for volumetric Doppler calculations cannot be obtained accurately 1
• Alternative approaches include:
  • 3D TEE to planimeter regurgitant orifices when available 1
  • In the absence of aortic regurgitation, calculating regurgitant volume as the difference between LV stroke volume (from 3D volume determinations) and LV forward flow (through the outflow tract) 1
• An integrated approach using multiple parameters is essential, as with native valve regurgitation 1

Assessment of Left Ventricular Remodeling

• Following successful reduction in mitral regurgitation, LV dimensions and volumes are expected to decrease 1
• A 6-month assessment with TTE is reasonable to evaluate reverse remodeling 1
• 3D speckle-tracking echocardiography, when available, can provide valuable information on both left and right ventricular function improvement 2

Monitoring for Complications

Early Complications

• Monitor for potential early complications including:
  • Partial dehiscence of the mitral valve clip 1
  • Leaflet or chordal tears 1
  • Pericardial effusion due to atrial wall perforation 1

Late Complications

• Monitor for development of mitral stenosis, particularly in patients who received multiple clips 3
  • Signs include elevated transmitral gradients and symptoms of heart failure 3
• Watch for recurrent mitral regurgitation, which may require additional intervention 1
  • A follow-up transesophageal echocardiography (TEE) allows improved understanding of the morphological causes of recurrent significant mitral regurgitation 1

Clinical Follow-Up

• Assess for improvement in New York Heart Association (NYHA) functional class 4
• Most patients (60%) achieve NYHA class I/II symptoms after successful MitraClip procedure 4
• Monitor for signs of heart failure, as patients with pre-existing right ventricular dysfunction may show less improvement in left ventricular function 2

Special Considerations

• Patients who underwent emergent MitraClip for cardiogenic shock require closer monitoring due to higher risk profile and poorer long-term survival rates 5
• CMR (Cardiac Magnetic Resonance) imaging may be considered in cases where echocardiographic assessment is challenging or inconclusive, as it provides excellent reproducibility for quantitation of residual mitral regurgitation 6

Follow-Up Schedule

• First follow-up: 1 month post-procedure
• Comprehensive assessment: 6 months post-procedure 1
• Subsequent follow-up: Annually or more frequently if residual/recurrent MR or clinical symptoms are present