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.
Comments are purely for informational purposes and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Disclaimer
If the clip can not be done (due to calcification) around the valve. What can one expect now? In jeopardy of dying soon?
Hi, I have edited the question to preserve your anonymity but great questions and i will address it fully for you.
In this case there is a severe leak of the valve and it is not something that has occurred overnight, rather it has been present a while. In this case we have a patient in their 90’s who is generally functional. The presenting symptoms were not shortness of breath or classic heart failure symptoms, rather they were coughing up blood. The leak of the mitral valve is severe however due to the way the valve is degenerated the procedure would be complex. I probably do amongst the most complex clip cases, and i have a good feel for those procedures that would be straightforward and those that would be very challenging, which allows for intelligent case selection and discussion. The worst thing we could do in this setting is make things worse. In valve that are this heavily calcified, there is a small chance of not only being unsuccessful but making the leak worse and worsening symptoms. The age means that emergency surgery back up is not a good option and so the threshold to be aggressive in a complex procedure needs to be considered carefully. Particularly in the case where the predominant symptoms are not swelling, shortness of breath etc. My advice in this case was to go home, see how he does with walking around and doing his usual activities then reevaluating. If he is unable to do activities that allow a decent quality of life, we feel more justified in proceeding, and to my way of thinking would certainly be willing to attempt it. If however, he is able to live a good quality of life then i don’t feel the procedure in this setting would be justified. The leak has been there a long time and there is no reason to think he would deteriorate suddenly.
I hope that was helpful.
Thank you so much.
Dr. Ahmed,
On June 16th, you performed MitraClip placement on my uncle, who suffered from a severe MI the Monday before. I just wanted to let you know how much my family and I appreciate your efforts with this procedure in particular and your decision to undertake his case, as I now understand how different his condition was in comparison with your other candidates for the MitraClip. It is my sincerest hope that he make a full and prosperous recovery, not only so that my family and I can enjoy having him with us longer, but also so that the success of his case may open the door for others in such critical condition to have the MitraClip as an option. Thank you so much for your efforts. May God bless you and your practice on medicine always.
I understand there is an alternative method of Mitral Valve repair ….Memo 3D Rechord Annuloplasty Ring System….it is FDA approved but is a different concept from the MitraClip… and I wonder what your experience, or assessment is, of this different procedure. My understanding is that it simplifies chordal reconstruction and replacement. Also, are the rings used for both Mitral and Tricuspid valve repair?
I am a 84 year old, active and totally mobile,….in good health…other than my heart valves….I would appreciate your comments!
The re-chord system is a surgical and not a non-surgical approach and is a method of placing chords in surgical mitral valve repair that is standard. The mitraclip is a percutaneous method that does not involve open surgery. Rings are used for both tricuspid and mitral repair. At the age of 84, the mitraclip may well be a better option if you are a candidate and the valve anatomy is amenable. I would seek an opinion at a center where both options are available to a high level and can be discussed.
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I am a 41 years old female, Sudanese staying in UAE I have a mitral valve regurgitation
Dotors in UAE advised me to do a mitral valve surgery.
I’d like to have your openion wether I need the sugery or not.
How severe is the MR do you have the full report details, is the valve repairable, do you have symptoms?
If you are interested in cutting edge information and therapy for heart disease then follow my twitter at @MustafaAhmedMD
how can I send you my reports
Vitalengine.com
Hi Dr Ahmed,
In order to prevent the heart attack in patients with mitraclip and constant form of atrium fibrillation, is it allowed to take Dabigatran etexilate or Apixapan instead of Warfarin?
For the mitraclip itself in general we just give aspirin, the anticoagulants that you mentioned are typically used for other reasons such as atrial fibrillation, if that is the case it doesn’t really matter which one is used with regards to the clip itself.
I am really grateful for your answer!
Dear Dr. Ahmed:
My mother in law is age 78 . Her cardiothoracic surgeon in Ukraine recommends MitraClip becaue she already had a SAVR operation in 2011 and cannot tolerate another open heart procedure. They can’t do the procedure there. The problem we have is she has no insurance and is an international patient. A well known private clinic in Jacksonville will do the operation but wants over six figures cash – my question is how can we find a medical provider in the southeast for MitraClip in the southeast that doesn’t want the proverbial arm and a leg? We know the clip itself costs in the neighborhood of 30K, so are ready to pay that and more. When we try university hospitals, they just never return our calls, faxes and emails, so we can’t even get a cash quote. Have you got any suggestions how to access treatment?
Contact the valve clinic at Princeton Baptist Medical Center, Birmingham, Alabama.
Do I have to have angiogram done before the clip procedure is done . I had angiogram in 2015 and shows a 3+. My last ECHO shows a 4 regurgitation. I am 81 and had a four bypass in 1998. I am not symptomatic at this point
Mitraclip should only be done in symptomatic people.
In general i perform angiogram in all my clip cases, one of the reasons being its akin to a surgical mitral valve repair procedure, and in the tiny chance surgical back up is required, one would really need to know the coronary anatomy prior to best handle the situation.
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My mom had the mitraclip done to repair a leaky valve. She was in the hospital a week, has beem back for 2 check ups. On the second check up they said the mitraclip was clipped to much. They are now talking open heart surgery, she is extremely high risk for open heart surgery.
1. is this malpractice, they had her a week and a follow up appointment and not till the second appointment did they catch this? 2 Can another clip be put in or the other fixed?
My mother had the mitraclip done. She was kept in the hospital a week due to other reasons. During the week she was in there everything far as the mitraclip was fine. She had a follow up appointment a month later, again everything was fine. She had a second follow up appointment and was told the clip was clipped to much and is not performing as it should…. The nurse(not the doctor) made the comment about open heart surgery. My mother his high risk. Would she be able to have the clip redone or another put in? Would this situation be considered malpractice, considering everything had been fine and now they say it was clipped to much? I would like to get feedback.
I of course cannot comment on the specifics of an individual case, the complexity of this is such that is differs very much so on a case by case basis. The critical question here is was the regurgitation severe in the first place, have significant symptoms, and was she prohibitive risk for surgery. If so then there was a good rational to proceed with the mitraclip. The next question is, does she feel better? If so then this is good, the aim has been achieved and there is no concern with a slightly high gradient (tightening per se) of the mitral valve. If the symptoms have worsened and the valve is felt to be too tight then there may be an issue, however further evaluation would be required to clarify. The risk of tightening depends on many factors that can often be identified prior to the case, it is often a balance getting the right amount of reduction in leak while preventing tightening. Tightening is not unheard of and is a known risk of the procedure however depends on factors such as experience and other. I would recommend starting by obtaining a consultation with the evaluating team and characterizing the valve itself prior to making next steps. Options such as surgery, only if required, can be discussed thereafter.
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