From the Guidelines
For optimal MitraClip referral as a noninvasive cardiologist, identify patients with symptomatic moderate-to-severe or severe mitral regurgitation (MR) who remain symptomatic despite guideline-directed medical therapy (GDMT), focusing on those with functional MR and reduced left ventricular ejection fraction (LVEF 20-50%) as demonstrated in the COAPT trial 1. To determine the best algorithm for MitraClip referral, consider the following key points:
- Identify patients with symptomatic moderate-to-severe or severe MR who remain symptomatic despite GDMT, with a focus on functional MR and reduced LVEF (20-50%) as shown in the COAPT trial 1.
- Ensure patients have appropriate anatomy for the procedure, including sufficient leaflet tissue for grasping, mitral valve area >4 cm², and absence of severe calcification at grasping sites.
- Optimize heart failure medications, including beta-blockers, ACE inhibitors/ARBs/ARNI, aldosterone antagonists, and SGLT2 inhibitors at target doses for at least 3 months, as maximally tolerated GDMT is a prerequisite for MitraClip referral.
- Document objective evidence of MR severity using comprehensive echocardiography with quantitative parameters, such as regurgitant volume, regurgitant fraction, and effective regurgitant orifice area, as outlined in the 2019 AATS/ACC/SCAI/STS expert consensus document 1.
- Assess functional status with 6-minute walk tests or cardiopulmonary exercise testing and document heart failure hospitalizations to determine the severity of symptoms and potential benefit from MitraClip therapy. The COAPT trial 1 demonstrated a marked reduction in hospitalizations for heart failure and improved survival with MitraClip therapy in patients with functional MR, highlighting the importance of appropriate patient selection for this procedure. By following this algorithm, noninvasive cardiologists can effectively identify patients who are most likely to benefit from MitraClip referral, ultimately improving symptoms, reducing heart failure hospitalizations, and potentially improving quality of life.
From the Research
MitraClip Referral Algorithm
The decision to refer a patient for MitraClip procedure as a noninvasive cardiologist involves several factors, including the severity of mitral regurgitation, left ventricular function, and surgical risk.
- The MitraClip procedure has been shown to be effective in reducing mitral regurgitation and improving clinical outcomes in patients with severe symptomatic mitral regurgitation who are at high or prohibitive risk for mitral valve surgery 2.
- Patient selection is crucial, and the latest generation MitraClip can increase procedural success, even in patients with challenging mitral valve anatomy 2.
- The REPAIR MR trial is ongoing to compare the outcomes of transcatheter edge-to-edge repair with the MitraClip and surgical repair of primary mitral regurgitation in older or moderate surgical risk patients 3.
Key Considerations
When considering referral for MitraClip, the following factors should be taken into account:
- Severity of mitral regurgitation: The MitraClip procedure is indicated for patients with severe symptomatic mitral regurgitation 2.
- Left ventricular function: The procedure has been shown to be effective in patients with reduced left ventricular ejection fraction (LVEF) and those with preserved LVEF 4.
- Surgical risk: The MitraClip procedure is an alternative to surgical mitral valve repair for patients who are at high or prohibitive risk for surgery 2, 3.
- Operator experience and center volume: The probability of achieving good procedural results is related to the experience of the operators and the volume of the center 5.
Special Considerations
In certain cases, the MitraClip procedure may be used as a bridge to heart transplantation, with the goal of reducing worsening and progression of underlying disease 6.
- The procedure has been shown to be safe and effective in patients with advanced heart failure and significant mitral regurgitation who are awaiting heart transplantation 6.