Mitral Valve Repair After MitraClip

Mitral valve replacement has become the default strategy for patients with recurrent or persistent mitral regurgitation after a failed transcatheter edge-to-edge repair (MitraClip), largely due to the technical challenges of repairing leaflets that have been altered by the clip. However, the authors believe this practice deserves reconsideration. With meticulous clip removal and reconstruction of the affected leaflet segments, durable mitral valve repair remains achievable in properly selected patients sparing them the long-term risks associated with a prosthetic valve (1, 2).

In a series of 17 patients, Gerfer et al. reported that 94 percent underwent mitral valve replacement after failure of transcatheter edge to edge repair (2). The main challenges included the high-risk nature of the patients and the complexity of repair techniques needed after clip removal.

This video presents a 76-year-old high-risk patient who developed persistent mitral regurgitation (grade III–IV) and concomitant tricuspid regurgitation (grade III–IV) following MitraClip therapy. His comorbidity profile included pulmonary hypertension (systolic pulmonary artery pressure (sPAP) 51 mmHg), chronic obstructive pulmonary disease, chronic renal insufficiency, and atrial fibrillation. Through a totally endoscopic, minimally invasive approach, the clip was carefully explanted, the mitral leaflets were reconstructed, and a concomitant tricuspid valve repair, cryoablation, and left atrial appendage (LAA) closure were performed in the same setting.

Postoperative echocardiography demonstrated an excellent result, with no residual mitral regurgitation and only minimal (trace) tricuspid regurgitation, confirming that a durable double valve repair can be achieved even after a failed clip and in the presence of significant comorbid disease.

This case illustrates that endoscopic mitral valve repair after failed MitraClip is not only technically feasible but can achieve outcomes comparable to primary repair, even in patients with elevated surgical risk. The authors advocate that repair-first strategies be more strongly considered in this growing patient population rather than defaulting to replacement, and they hope this video encourages broader adoption of minimally invasive repair techniques in redo mitral surgery after failed transcatheter intervention.

References

1. Olsthoorn J, Heuts S, Maessen J, Sardari Nia P. Mitral valve repair after failed MitraClip therapy. Multimed Man Cardiothorac Surg. 2019 Sep 30;2019. doi: 10.1510/mmcts.2019.027. PMID: 31593378. 
2. Gerfer S, Ivanov B, Großmann C, Djordjevic I, Gaisendrees C, Eghbalzadeh K, Kuhn E, Kuhn-Régnier F, Mader N, Rahmanian P, Wahlers T. Mitral valve surgery after failed MitraClip-Operation for the inoperable? J Card Surg. 2022 Dec;37(12):4219-4224. doi: 10.1111/jocs.16762. Epub 2022 Jul 17. PMID: 35842819. 

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