From the Guidelines
This patient should not undergo MitraClip placement at this time, and instead, the next step should be optimization of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). The patient has severe functional mitral regurgitation secondary to left ventricular dilation and dysfunction, but his current medication regimen is significantly under-dosed.
- The carvedilol dose should be uptitrated to a target of 25mg twice daily,
- valsartan increased to 160mg twice daily, and
- spironolactone to 25-50mg daily. Additionally,
- sacubitril/valsartan should be considered to replace the valsartan alone, and
- dapagliflozin or empagliflozin should be optimized. The patient would also benefit from adding a loop diuretic given his elevated filling pressures (PCW 24mmHg). After 3-6 months of optimized GDMT, the patient should undergo repeat echocardiography to reassess ventricular function and mitral regurgitation severity. MitraClip could be reconsidered if severe MR persists despite optimal medical therapy. The rationale is that functional MR often improves with optimal heart failure treatment, and the COAPT trial demonstrated benefit of MitraClip primarily in patients who remained symptomatic despite maximally tolerated GDMT 1. This patient's elevated BNP, recurrent heart failure hospitalizations, and hemodynamic profile suggest inadequate treatment rather than a primary valvular problem requiring immediate intervention. The most recent guidelines and recommendations support this approach, emphasizing the importance of a multidisciplinary team in the management of these patients and the role of noninvasive imaging in monitoring asymptomatic patients 1.
From the Research
Patient Profile
- Age: 63 years
- Weight: 67 kg
- Height: 12 cm (not a standard measurement, possibly an error)
- Diagnosis: Heart Failure with reduced Ejection Fraction (HFrEF), Non-Ischemic Cardiomyopathy (NICM), Left Ventricular End-Diastolic Diameter (LVEDD) 7.4 cm
- Comorbidities: Chronic Kidney Disease (CKD) stage 3b, Hypertension (HTN), Hyperlipidemia (HLD), Right Lower Lobe (RLL) nodule, malnutrition
- Medications: Carvedilol, Jardiance, Valsartan, Spironolactone, Atorvastatin
Clinical Findings
- EKG (4/2025): Normal Sinus Rhythm (NSR), Left Ventricular Hypertrophy (LVH) with repolarization abnormality, QRS duration 110 ms
- Labs (4/2025): ProBNP 20,679, HS-Trop 142, CT 198, LDL 152, HDL 34, Triglycerides 61, TSH 2.0, A1C 4.6%
- TTE (4/2025): Left Ventricular Ejection Fraction (LVEF) 20%, Left Ventricular (LV) dilated, severe Mitral Regurgitation (MR), moderate Pulmonary Hypertension (PHTN)
- LHC (4/2025): Non-obstructive Coronary Artery Disease (CAD)
- RHC (4/2025): Right Atrial (RA) pressure 7 mmHg, Right Ventricular (RV) pressure 60/7 mmHg, Pulmonary Artery (PA) pressure 70/30 mmHg, Pulmonary Capillary Wedge Pressure (PCWP) 24 mmHg
MitraClip Consideration
- The patient has severe Mitral Regurgitation (MR) with a LVEF of 20%, which is a significant predictor of mortality 2
- The study by 3 suggests that LVEF may not adequately reflect LV systolic function in patients with MR
- Forward LVEF has been proposed as a simple risk marker in patients with primary MR 4
- Changes in LVEF after Mitral Valve Repair (MVr) for primary MR have been studied, and the results suggest that preoperative LVEF and LVESD can predict postoperative LVEF changes 5
- The patient's complex profile, with multiple comorbidities, makes them a "complex patient" 6, requiring careful consideration of treatment options
Next Steps
- Consider MitraClip procedure for severe MR, given the patient's LVEF and symptoms
- Evaluate the patient's suitability for MitraClip based on echocardiographic parameters and clinical criteria
- Discuss the risks and benefits of the procedure with the patient and their family
- Consider a multidisciplinary approach to manage the patient's complex condition, including cardiology, nephrology, and other relevant specialties