Should a 63-year-old male with Heart Failure with Reduced Ejection Fraction (HFrEF) (Ejection Fraction 15-20%), Non-Ischemic Cardiomyopathy (NICM), Left Ventricular End-Diastolic Diameter (LVEDD) 7.4cm, history of Cerebrovascular Accident (CVA), Chronic Kidney Disease (CKD) stage 3b, Hypertension (HTN), Hyperlipidemia (HLD), and severe Mitral Regurgitation (MR) be considered for a MitraClip procedure?

From the Guidelines

This patient is a strong candidate for a MitraClip procedure, given his severe heart failure with reduced ejection fraction (HFrEF), significant left ventricular dilation, and severe mitral regurgitation (MR) despite maximized guideline-directed medical therapy (GDMT) 1. The severe MR is likely secondary to his dilated cardiomyopathy (functional MR) and is contributing to his recurrent heart failure hospitalizations. The patient's right heart catheterization shows elevated pulmonary pressures (PASP 55 mmHg) and pulmonary capillary wedge pressure (24 mmHg), confirming significant left-sided congestion. His severely dilated left ventricle (LVEDD 7.2 cm) with an EF of only 20% indicates advanced heart failure. The MitraClip procedure would reduce the mitral regurgitation, potentially improving his symptoms, reducing hospitalizations, and possibly allowing for better tolerance of heart failure medications.

Some key points to consider:

• The patient has already been maximized on GDMT but cannot tolerate further uptitration due to hypotension, suggesting he has reached the ceiling of medical management.
• The COAPT trial demonstrated a marked reduction in the primary efficacy endpoint of all hospitalizations for HF within 24 months with the use of the MitraClip device in patients with similar characteristics to this patient 1.
• Before proceeding with MitraClip, a transesophageal echocardiogram (TEE) should be performed to better characterize the mitral valve anatomy and confirm suitability for the procedure.
• The patient should also be evaluated by a multidisciplinary heart team including an interventional cardiologist, heart failure specialist, and cardiac surgeon to determine if he meets criteria for the procedure based on the COAPT trial.
• Given his advanced heart failure, consideration should also be given to evaluation for advanced heart failure therapies including left ventricular assist device or heart transplantation as part of his comprehensive management plan.

From the Research

Patient Profile

• Age: 63
• Weight: 67 kg
• Height: 12 cm (not applicable, likely a typo)
• Diagnosis: Heart Failure with reduced Ejection Fraction (HFrEF), Chronic Kidney Disease (CKD) stage 3b, Hypertension (HTN), Hyperlipidemia (HLD), Right Lower Lobe (RLL) nodule, malnutrition
• Medical History: Cerebrovascular Accident (CVA) with Right Middle Cerebral Artery (R-MCA) involvement, Left Hemiplegia (2023), Acute Decompensated Heart Failure (ADHF) hospitalizations (August 2024 and March 2025)
• Medications: Carvedilol, Jardiance, Valsartan, Spironolactone, Atorvastatin

Current Condition

• EKG (April 2025): Normal Sinus Rhythm (NSR), Left Ventricular Hypertrophy (LVH) with repolarization abnormality, QRS duration 110 ms
• Labs (April 2025): White Blood Cell (WBC) count 6.4, Hemoglobin (Hb) 14.6, Hematocrit (HCT) 42.1, Platelet (PLT) count 214, Creatinine 1.5, Potassium 4.8, Liver Function Tests (LFT) within normal limits, Pro-B-Type Natriuretic Peptide (ProBNP) 20,679, High-Sensitivity Troponin (HS-Trop) 142
• Transthoracic Echocardiogram (TTE) (April 2025): Left Ventricular Ejection Fraction (LVEF) 20%, Left Ventricular (LV) dilation, severe Mitral Regurgitation (MR), moderate Pulmonary Hypertension (PHTN)
• Left Heart Catheterization (LHC) (April 2025): non-obstructive Coronary Artery Disease (CAD)
• Right Heart Catheterization (RHC) (April 2025): Pulmonary Artery Pressure 70/30 mmHg, Pulmonary Capillary Wedge Pressure 24 mmHg

Considerations for MitraClip Implantation

• The patient has severe functional Mitral Regurgitation (FMR) despite optimal medical therapy, which is a indication for MitraClip implantation 2, 3
• The patient has a history of ADHF hospitalizations, which suggests that FMR is contributing to the patient's symptoms and disease progression 2, 3
• The patient's LVEF is severely reduced, which may limit the effectiveness of MitraClip implantation, but some studies suggest that MitraClip can still provide benefits in patients with severe left ventricular dysfunction 4, 5
• The patient's pulmonary hypertension and right ventricular dysfunction may also impact the effectiveness of MitraClip implantation, and require careful consideration in the decision-making process 6

Next Steps

• Consider MitraClip implantation as a treatment option for severe FMR, taking into account the patient's overall clinical profile and potential benefits and risks 4, 2, 3, 5
• Discuss the patient's case with a Heart Team, including cardiologists, cardiothoracic surgeons, and other relevant specialists, to determine the best course of treatment 6
• Continue to optimize medical therapy and monitor the patient's condition closely, with regular follow-up appointments and diagnostic testing as needed.