MitraClip in Chordal Rupture
MitraClip can be used for mitral regurgitation due to chordal rupture (flail leaflet) in high-risk surgical patients with favorable anatomy, but surgical repair remains the gold standard and should be performed whenever feasible. 1, 2
Primary Indication Hierarchy
Surgical mitral valve repair is the definitive treatment for severe mitral regurgitation from chordal rupture and must be prioritized in all patients who can tolerate surgery. 1, 2 MitraClip is explicitly reserved as a second-line option for a specific subset of patients. 1, 2
When to Consider MitraClip for Chordal Rupture
MitraClip may be considered when all of the following criteria are met:
- Severe symptoms (NYHA class III-IV) despite optimal medical management 1, 2
- Prohibitive surgical risk due to severe comorbidities (not simply advanced age alone) 1, 2
- Reasonable life expectancy (>1 year) 2
- Favorable anatomic features as detailed below 1, 2
Critical Anatomic Requirements for Success
The following echocardiographic parameters must be satisfied for MitraClip consideration in flail leaflets:
- Flail gap <10 mm (distance between flail segment and opposing leaflet) 1
- Flail width <15 mm 1
- Pathology located centrally at A2/P2 segments (lateral or medial pathology has poor outcomes) 1, 2
- Mitral valve area ≥4 cm² and mean gradient <4 mmHg at rest 1, 2
- No significant leaflet calcification at the grasping site 1
Absolute Contraindications
Do not proceed with MitraClip in the following scenarios:
- Pre-existing mitral stenosis (valve area <4 cm² or mean gradient >4 mmHg) 1, 2
- Active endocarditis 2
- Intracardiac thrombus 2
- Rheumatic valve disease with restricted leaflet motion (Carpentier Type IIIA) - this will create severe mitral stenosis 2
- Short posterior leaflet (<8 mm length) 1
Expected Outcomes in Chordal Rupture
- Procedural success rate approximately 75% with reduction of MR to ≤2+ 2
- Less effective than surgery at eliminating mitral regurgitation, but provides symptomatic improvement and reverse LV remodeling 1, 2
- 86% of patients achieve ≤2+ MR at follow-up 3
- In degenerative MR (including chordal rupture), the clip anchors the flail leaflet to restore coaptation 1
Critical Pitfalls to Avoid
The most important error is using MitraClip in patients who are actually surgical candidates. 2 The device was designed for prohibitive surgical risk, not as a convenience or patient preference in operable candidates. 1
Failed MitraClip therapy complicates subsequent surgery. 4, 5 Leaflet injury from prior clip placement can necessitate valve replacement instead of repair in 33-67% of cases requiring surgical revision. 4, 5 This is particularly problematic in younger patients who would otherwise be excellent candidates for durable surgical repair. 4
Do not expand selection criteria to healthier patients - primary surgical repair may be precluded by clip-induced leaflet damage. 4
Mandatory Pre-Procedural Evaluation
- Transthoracic echocardiography for initial screening and severity assessment 2
- 3D transesophageal echocardiography is mandatory to confirm anatomic eligibility and guide the procedure 1, 2
- Heart Team evaluation including interventional cardiologists, cardiac surgeons, heart failure specialists, and imaging experts 2
Severe MR must be confirmed by: vena contracta ≥7 mm, EROA ≥0.4 cm² (primary MR), regurgitant volume ≥60 mL/beat, and regurgitant fraction ≥50%. 2
Procedural Considerations
The procedure requires general anesthesia with continuous 3D TEE and fluoroscopic guidance. 1, 6 The device is deployed at the A2/P2 interface after transseptal puncture, with the clip grasping both leaflets to create a double-orifice valve. 1 Multiple clips may be placed if needed to achieve adequate MR reduction. 1
When Surgery Remains Superior
Even in high-risk patients, surgical repair should be reconsidered if: