Therapeutic Strategy in the era of MitraClip and Ventricular Assist Device.

Abstract

To the editor: Given the increasing number of patients with advanced heart failure and functional mitral regurgitation receiving percutaneous transcatheter edge-to-edge mitral valve repair using MitraClip system (Abbott Vascular, Chicago, IL), surgeons may face situations when durable left ventricular assist devices (LVAD) are implanted in patients with an existing MitraClip. Kirali and colleagues reported two patients who received concomitant MitraClip removal and LVAD implantation with successful clinical results.1 We congratulate the authors on successful LVAD implantation and concomitant MitraClip removal. During LVAD support, the unremoved clips might migrate due to continuous blood removal via inflow cannula located in the apex even without any clip-related complications. In their case, clips were removed in both patients to manage clip-related complications. With this in mind, it is unclear if the MitraClip should be removed irrespective of the presence of clip-related complications at the time of LVAD implantation. Given that durable LVAD therapy has the potential to ameliorate significant mitral regurgitation due to cardiac unloading,2,3 it may be a better durable option, instead of MitraClip therapy, for carefully selected patients with considerable functional regurgitation and significant left ventricular dysfunction. The long-term benefit of MitraClip remains unclear as it relates to progression of mitral regurgitation and recurrence of symptoms. Our team recently demonstrated that elevated pulmonary artery pressure and reduced left ventricular ejection fraction at baseline was associated with lower survival free from heart failure readmission in patients who received a MitraClip.4 Future randomized clinical trials are needed to better understand which patients may benefit from either direct MitraClip procedure (and successive LVAD therapy) or upfront LVAD implantation.