The Mitraclip procedure for mitral regurgitation is performed on a leaky mitral valve. This article presents a broad overview of the procedure and the people who need it. For a detailed overview of the MitraClip procedure itself, please see our article How to do the MitraClip Procedure – A Complete Guide. A leaking mitral valve can be seen in the image below. The blue jet shows the leak, and represents blood leaking backwards – from the bottom to the top chamber of the heart – through mitral valve. The medical term for the leaky mitral valve is mitral regurgitation. The Mitraclip is a new treatment for severe mitral regurgitation that does not require open-heart surgery.
Mitraclip Is Performed Through A Small Hole In The Groin – No Open Heart Surgery Is Required
The Mitraclip procedure is performed through a small incision in the groin unlike usual mitral valve surgery that requires sawing open of the breastbone. A tube is passed up through the leg vessels to the right side of the heart and the tube then passed in to the left side of the heart using a technique known as trans-septal puncture as seen below. This is a very specialized technique and gives us access to the mitral valve.
The Mitraclip Is Controlled By A Delivery System That Remains Outside The Body
The Mitraclip is then passed up through this tube and in to the left side of the heart, connected to a delivery system. The delivery system is an instrument that remains outside the body and allows us to control the delivery of the Mitraclip. It is very important care is taken ensure no air bubbles get in to the heart. The blood is kept thin using a blood thinner called heparin to ensure no clots form on the delivery system.
The Mitraclip is then positioned over the leaky mitral valve and using the delivery system, small adjustments are made to ensure the clip is in the desired position. The arms of the clip can be opened and closed, and the clip can be turned clockwise or counterclockwise as required. This is shown below.
With the arms opened, the Mitraclip is passed down below the mitral valve. After further positioning the Mitraclip pulled back upwards and the mitral leaflets are grasped. The clips are then closed and the valve reassessed to ensure that there is a reduction in the mitral regurgitation. If there is not the desired reduction in the mitral regurgitation then the Mitraclip may need to undergo further repositioning before it is released.
The arms of the Mitraclip are then closed and the Mitraclip secured into position. The Mitraclip is then detached from the delivery system. The delivery system is then withdrawn. The Mitraclip remains firmly attached to the mitral valve leaflets.
The Mitraclip Remains Securely Attached To The Mitral Valve Leaflets
With correct positioning of the Mitraclip, the mitral regurgitation is reduced to minimal levels and the procedure successfully completed. In many cases, one Mitraclip isn’t enough and a second, or even third Mitraclip will need to be deployed to achieve the desired result. The Mitraclip remains securely in position tightly bound to the mitral valve leaflets.
Benefits of the Procedure
Most of the proven benefits of reduction of severity of mitral regurgitation by the Mitraclip are quality of life and not length of life. This is likely because the follow up time from experience with the Mitraclip is still in its early years.
- Improved quality of life
- Improvement in symptoms
- Decreased chance of being hospitalized
- Favorable reduction in heart size
- Improvement in heart shape
- Reduction in mitral regurgitation
- Avoidance of prohibitively high surgical risk
What Are The Risks?
All in all the Mitraclip procedure can be considered safe as determined by experience from use of thousands of devices. The chance of procedural success is >90%, and the chance of surviving the procedure is >99%. As with any invasive procedure, even minimally invasive there are risks associated however. It’s why you want a truly expert team guiding the procedure.
- Even though the tube inserted in to the leg for the Mitraclip is not a surgical incision, there is still a small risk of damage to the blood vessels or infection at the entry site.
- As with anytime working inside the heart, there is chance of damage to cardiac structures including the valves, the vessels, or the walls of the heart. There is a chance of leakage of blood outside the walls of the heart that may require further procedures to take care of it.
- There is a small chance of clot developing on the tubes in the heart or air getting in to the heart, the consequence of which could be a stroke amongst other complications. Care is taken to minimize this.
- There is a chance that the hole made to travel from the right to the left of the heart, doesn’t close on its own and leaves a persistent defect. Rarely this may need to be closed with another procedure.
What Kind of Doctor Performs The MitraClip Procedure?
An interventional cardiologist that specializes in structural heart disease performs the Mitraclip procedure. A heart team approach is required for Mitraclip patient selection and consists of an interventional structural cardiologist, a cardiac surgeon, and a cardiologist specializing in imaging and valvular heart disease. During the procedure itself the imaging specialist is key, as pictures need to be obtained and interpreted in a 3-Dimensional fashion. It is important that the interventional cardiologist performing the procedure is well trained in imaging also. I know I had a large advantage when starting this procedure because I had advanced understanding of both imaging and structural intervention, allowing an immediate understanding of working in the heart in 3-dimensions.
How Long Does The Mitraclip Procedure Take?
The whole process has 3 steps: the pre-procedure, the procedure, and post-procedure recovery.
- Most patients will have been assessed in clinic to assess suitability for the Mitraclip procedure.
- Patients arrive on the morning of the procedure. Some basic lab tests are done and the patient will meet the anesthesiologist.
- In the procedure room, the patient will be put to sleep for the procedure and a breathing tube inserted. This will usually be taken out as soon as the procedure is done.
- In experienced centers, the procedure itself can take from 1 to 3 hours. Sometimes it can be longer if required depending on the complexity of the case.
- After the procedure the patient will go to a recovery area and when felt to be stable enough, sent to a room in the hospital.
- I usually send patients home the next day in the early afternoon.
Am I Eligible to Have a MitraClip Procedure?
Across the world there has been considerable experience with the Mitraclip, particularly in Europe. Thousands of Mitraclips have been implanted. There is growing experience in the US with the Mitraclip, however the indications for use in the US are more restrictive. The reason for this is that the FDA requires further high quality evidence before the indications are widened. As of now, in the US, the Mitraclip is only approved for severe degenerative mitral regurgitation.
Current indications for the Mitraclip are as follows in the United States:
- Severe mitral regurgitation that is primary in nature. This means the primary problem is with the valve itself (i.e. mitral valve prolapse, a problem with the valve leaflets themselves) as opposed to secondary mitral regurgitation (i.e. severely enlarged heart causing the valve problem).
- The patient is considered to be at too high risk for normal mitral valve surgery.
- A specialist heart team that includes a surgeon experienced in mitral valve surgery and a cardiologist that is experienced in the management of valvular heart disease and the Mitraclip has assessed the case.
What Patients Should Not Have the Mitraclip?
- Patients at high risk of bleeding, and who will not be able to tolerate the blood thinning medicines given at the time of the procedure and those required after the procedure.
- Patients with an active infection of the mitral valve
- Patients determined to have rheumatic heart disease, and are therefore at risk of developing an overly tight mitral valve if the Mitraclip is used.
- Patients that have clot inside the heart, or inside the vessels through which the Mitraclip is delivered to the heart.
Ideal Patient for MitraClip
- These judgments of high risk are determined by cardiologists who specialize in valvular heart disease and the Mitraclip, together with a cardiac surgeon that is experienced in mitral valve surgery.
- Patients who have a calculated 30 day risk of death of >8% for surgical mitral valve replacement of >6% for surgical mitral valve repair.
- Patients with prohibitive anatomy for surgery such as porcelain aorta that would make conventional surgery too high risk.
- Patients with factors that make surgery too high risk that include severe liver disease, or severely high pressures in the lung arteries
- Patients simply felt to be too frail for open heart surgery
- Other circumstances that would make surgery inadvisable such as dementia, right sided heart dysfunction, chronic illness etc.