If you have mitral regurgitation and have been told that MitraClip may be an option, you may also be questioning how it compares with mitral valve surgery.
Both are used to treat a leaking mitral valve, but they treat the problem differently. Which one is right for you will depend on why your valve is leaking, if it can be repaired, your heart function, other cardiac conditions, your surgical risk and the anatomy of the valve.
At CTSurg, Dr Adrian Pick regularly sees patients who have been told they may need a mitral valve procedure, or who want to understand the difference between transcatheter treatment and surgical mitral valve repair.
What is MitraClip?
MitraClip is a brand name for a transcatheter edge-to-edge repair device, also known as TEER. It is used to treat mitral regurgitation, where the mitral valve does not close properly and blood leaks backwards inside the heart.
The procedure is performed through a catheter, usually inserted through a vein in the groin. The clip is guided to the mitral valve and used to bring part of the valve leaflets together. This may reduce the amount of leakage.
Because it avoids a chest incision and heart-lung bypass, MitraClip can be a useful option for selected patients depending on the cause of the mitral regurgitation (MR), valve anatomy and surgical risk.
How is Mitral Valve Surgery different?
Surgical mitral valve repair allows the surgeon to assess the valve directly, repair damaged leaflets, treat stretched or weakened valve support structures and reshape the valve opening with an annuloplasty ring (if needed).
MitraClip works by clipping the valve leaflets together which can reduce the leak, but it may not correct the underlying valve problem.
If the mitral valve itself is damaged, such as with mitral valve prolapse or a flail leaflet, surgical repair may be considered when the valve is repairable and the patient is suitable for surgery. Surgery has an established place in severe primary mitral regurgitation, with TEER more relevant for patients considered at increased surgical risk.
Surgery may also allow another cardiac condition to be treated during the same operation, such as atrial fibrillation, coronary artery disease or tricuspid valve disease, where this is clinically indicated.
Brief comparison of MitraClip and Mitral Valve Surgery
| MitraClip / TEER | Mitral valve surgery | |
| Access | Catheter, usually through a vein in the groin | Surgical, to the heart, through minimally invasive procedure or sternotomy |
| What it does | Brings part of the valve leaflets together to reduce regurgitation | Repair of the valve structures or valve replacement, if required. More likely to eliminate regurgitation completely. |
| Patient suitability | Selected patients based on the type of MR, anatomy, symptoms and surgical risk | Patients whose valve disease and overall health make surgical treatment suitable. Best for degenerative regurgitation. |
| Other cardiac conditions | Treats the mitral valve leak being targeted | Other cardiac conditions may be addressed during the same operation if clinically suitable |
How the cause of MR affects treatment
The cause of mitral regurgitation helps determine if treatment needs to target the valve itself or the heart condition causing the leak.
Primary mitral regurgitation starts with a problem in the valve, such as mitral valve prolapse or a flail leaflet. If the leak is severe, the valve is repairable and the patient is fit for surgery, surgical repair can directly correct the damaged valve. MitraClip reduces the leak by bringing the leaflets together, but it does not repair the valve in the same way.
Mitral valve surgery can also enter the discussion when the valve anatomy does not suit MitraClip, atrial fibrillation or another cardiac problem can be treated at the same time and if MitraClip has not controlled the leak.
Secondary mitral regurgitation develops when the heart enlarges or weakens and pulls the valve out of shape. Treatment usually starts with the underlying heart condition. If significant leakage and symptoms continue, MitraClip can be an option.
MitraClip and surgery treat mitral regurgitation differently, so the cause of the leak helps guide which option fits the situation.
How valve anatomy affects treatment
MitraClip relies on being able to grasp enough healthy leaflet tissue, and some valves are not suitable because of the shape, size, movement or quality of the leaflets.
This can be due to severe calcification, a very large gap between the leaflets, multiple leaking areas, short or restricted leaflets or mitral valve narrowing. In these situations, a clip may not reduce the leak enough or it may increase the risk of mitral stenosis, where the valve becomes too narrow.
A detailed echocardiogram, usually including transoesophageal echocardiography, is usually needed before deciding if the anatomy is suitable. The same imaging also helps determine if surgical valve repair is feasible and what type of repair may be required.
Can mitral regurgitation return?
A MitraClip can reduce mitral regurgitation, but the leak can persist or return over time. If surgery is needed after MitraClip, the operation is more complex and valve replacement may be required rather than repair.
This is why it can be useful to understand if your valve is suitable for surgical repair before deciding on MitraClip, especially if you are fit for surgery.
Dr Adrian Pick assesses patients for mitral valve repair, including minimally invasive surgical options where suitable. A surgical opinion can help you understand if repair is an option now or what treatment choices remain if MitraClip has not controlled the leak.
Choosing between MitraClip and Mitral Valve Surgery
TThe right treatment for mitral regurgitation should not be based on one reason alone, such as age, symptoms or the appeal of a less invasive procedure.
Transcatheter mitral valve treatment should include a multidisciplinary Heart Team review for each individual patient. A proper decision takes into account:
- The cause of the mitral regurgitation
- The severity of the leak
- Valve anatomy
- Heart function
- Surgical risk
- Other heart conditions
- Life expectancy and recovery goals
- The likelihood of a durable result
MitraClip may be a sensible option for some and mitral valve repair surgery may be a better option for others. It is also possible that patients may just need monitoring and medical care.
When to ask for a specialist assessment
If you have been diagnosed with mitral regurgitation, your GP and cardiologist can help coordinate investigation and treatment based on your symptoms, echocardiogram and overall heart health.
If MitraClip is being discussed, ask your doctor to refer you to Melbourne-based Cardiothoracic Specialist, Dr Adrian Pick, consulting in Frankston and Moorabbin.
Obtaining a surgical opinion does not commit you to surgery. It is to help establish if mitral valve repair is another option and what aspects influence the suitability of one treatment over another after expert review of your imaging, valve anatomy, heart function, other cardiac conditions and general health.
Frequently asked questions
Is MitraClip only considered when someone cannot have surgery?
It comes down more to the type of mitral regurgitation and the individual patient’s circumstances.
Can I still have mitral valve surgery after a MitraClip?
Yes. Surgery can still be performed after previous TEER. The procedure is more technically complex, and the condition of the valve can influence if repair or replacement is considered.
Should I get a surgical opinion before having MitraClip?
If MitraClip has been recommended, a surgical opinion can help confirm if mitral valve repair is an option. A specialist assessment will review your valve anatomy, the cause of the leak, your heart health and if you are suitable for surgery before treatment is decided.
This article is for general information only and should not replace medical advice from your GP, cardiologist or treating specialist. All medical and surgical procedures carry risks and outcomes vary between patients. Consult with Mr Adrian Pick MBBS, FRACS | Gen Surg, FRACS | Cardiothoracic (MED0001117736) is a Cardiothoracic Specialist for personalised treatment and advice.
Reference:
Muller, D. W. M., Almeida, A., Camuglia, A., Walters, D., Passage, J., Scalia, G. M., Bhindi, R., Lo, S., Bennetts, J., Walton, A., Cardiac Society of Australia and New Zealand, & Australia and New Zealand Society of Cardiac and Thoracic Surgery. (2021). Operator and institutional requirements for transcatheter mitral valve therapies in Australia: A CSANZ and ANZSCTS position statement. Heart, Lung and Circulation, 30(12), 1805–1810. https://www.sciencedirect.com/science/article/abs/pii/S1443950621011161