From the Guidelines
This patient should be considered for a MitraClip procedure given his severe functional mitral regurgitation (MR) with heart failure with reduced ejection fraction (HFrEF) that remains symptomatic despite guideline-directed medical therapy (GDMT). The patient has had two recent heart failure hospitalizations despite being on multiple heart failure medications, and further medication uptitration is limited by hypotension. His echocardiogram shows severe MR with significant left ventricular dilation (LVEDD 7.2 cm) and dysfunction (EF 20%), and his right heart catheterization confirms elevated filling pressures (PCW 24 mmHg) with pulmonary hypertension.
Key Points to Consider
- The patient's symptoms and MR severity persist despite maximally tolerated GDMT, which is a key indication for edge-to-edge clip repair, as noted in the 2019 AATS/ACC/SCAI/STS expert consensus systems of care document 1.
- The COAPT trial, which is the highest quality study on this topic, demonstrated a marked reduction in hospitalizations for heart failure and a reduction in all-cause death in patients with HF and secondary MR who underwent edge-to-edge clip repair compared to medical therapy alone 1.
- The patient's anatomy, as assessed by transthoracic echocardiogram (TTE), appears suitable for the MitraClip procedure, with severe MR and a left ventricular ejection fraction (LVEF) of 20%.
- A transesophageal echocardiogram should be performed to further assess mitral valve anatomy and confirm suitability for the procedure.
Next Steps
- The patient should be evaluated by a multidisciplinary heart team, including an interventional cardiologist, cardiac surgeon, and heart failure specialist, to determine if he is an appropriate candidate for the MitraClip procedure.
- The patient's overall clinical status, including his history of CVA, CKD, and malnutrition, should be carefully considered in the decision-making process.
- The potential benefits of the MitraClip procedure, including reduction of mitral regurgitation, improvement of symptoms, reduction of heart failure hospitalizations, and potential improvement in survival, should be weighed against the potential risks and complications of the procedure.
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), 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
- Medications: Carvedilol, Jardiance, Valsartan, Spironolactone, Atorvastatin
Current Condition
- Recent hospitalizations for Acute Decompensated Heart Failure (ADHF) in August 2024 and March 2025
- Echocardiogram (TTE) showing Left Ventricular Ejection Fraction (LVEF) of 20%, severe Mitral Regurgitation (MR), and Left Ventricular (LV) dilation
- Unable to tolerate further Guideline-Directed Medical Therapy (GDMT) due to hypotension
Consideration for MitraClip
- The patient has severe MR, which is a common valvular disorder often seen in patients with severely dilated LV and reduced LV function 2, 3
- The MitraClip device has been shown to be a safe and effective treatment option for patients with severe MR and advanced heart failure, including those who are not candidates for surgical therapy 2, 4
- The patient's current condition, including severe MR, advanced heart failure, and inability to tolerate GDMT, may make them a suitable candidate for the MitraClip procedure 3, 5
- Additionally, the MitraClip procedure has been shown to improve renal function in patients with cardio-renal syndrome, which may be beneficial for the patient's CKD stage 3b 6
Next Steps
- Further evaluation by a multidisciplinary team, including cardiologists, cardiothoracic surgeons, and other specialists, to determine the patient's suitability for the MitraClip procedure
- Consideration of the patient's overall clinical condition, including their heart failure status, renal function, and other comorbidities, in making a decision about the MitraClip procedure
- Discussion with the patient and their family about the potential benefits and risks of the MitraClip procedure, as well as alternative treatment options 2, 3, 4, 6, 5