Restrictive Annuloplasty Research Articles

Reparación de la insuficiencia mitral funcional mediante abordaje del aparato subvalvular. Resultados a medio plazo

Introduction and objectivesSurgical treatment of functional mitral regurgitation still remains an issue widely debated due to its high morbidity and mortality and the absence of consensus about the best therapeutic option (repair vs replacement). We present our mid-term experience in its treatment with a repair approaching de subvalvular apparatus. MethodsBetween 2012 and 2016, 16 patients were operated on in our hospital with a moderate to severe mitral regurgitation due to a Carpentier's type IIIb mechanism. The mean logistic EuroSCORE was 10.81%. In all of them a restrictive ring annuloplasty was carried out, along with the relocation of the posteromedial papillary muscle in 14 patients and the approximation of the papillary muscles in 2 patients. Other procedures were carried out in 12 of these 16 patients. ResultsThe mean follow up period was 29.5 months. There were 2 perioperative deaths. There were no more deaths during the follow up. The recurrence of mitral regurgitation > 2 was 12.5% (2 patients). Only these 2 patients with a mitral regurgitation > 2 in the follow up echocardiograms needed hospital readmission at some point due to decompensated heart failure, remaining the rest of them in NYHA class i-ii/iv. ConclusionsApproaching the subvalvular apparatus in the repair of functional mitral regurgitation seems to be a valuable option in the treatment of this kind of regurgitation, offering optimal results in terms of survival at discharge and in recurrence at mid-term follow up.

Biomechanics raises solution to avoid geometric mitral valve configuration abnormalities in ischemic mitral regurgitation.

Ischemic mitral regurgitation (IMR) is a form of mitral insufficiency that is characterized by papillary muscle (PM) displacement, leaflet tethering, reduced closing forces, and different degree of annular dilatation. Treatment of this condition includes mitral valve replacement or mitral valve repair with restrictive annuloplasty. Recent evidences in mitral valve repair showed that addressing only the annulus and neglecting the subvalvular apparatus provides a suboptimal operation with poor long-term results. However, the complexity of the geometrical aberrances occurring in IMR demands for more accurate analysis also involving the biomechanics underlying the failing mitral valve and subvalvular apparatus. Finite element analysis (FEA) is a powerful tool in this context and we developed a biomechanical model of mitral valve and subvalvular unit using 3D geometry of the leaflets, annulus, chordae and PM. After the application of structural properties of materials to these elements and simulation of systemic pressure loading, FEA could be used to directly determine biomechanical changes and geometry variations. We believe this approach can provide valuable information to better address the surgical treatment of IMR and answer some of the questions still pending in IMR management.

Functional mitral stenosis following mitral valve repair.

This review summarizes the evidence describing functional mitral stenosis (MS) following surgical mitral valve repair. Functional MS is an evolving concept and has been implicated in the repair of functional and organic mitral regurgitation. Following repair of functional mitral regurgitation, an elevation in peak transmitral gradient and pulmonary artery pressure has been observed under physiologic stress. These changes have been associated with worse functional status early after restrictive annuloplasty. Following repair of organic mitral regurgitation, functional MS has also been observed and appears associated with worse functional status late after surgery. Because repair of functional mitral regurgitation commonly involves restrictive annuloplasty, the issue of functional MS must be weighed against the benefits and durability of repair. Functional MS following repair of degenerative mitral regurgitation, however, may be modifiable. Research evaluating various repair techniques and their impact on functional MS following repair of organic is ongoing.

Predictors and Clinical Impact of Functional Mitral Stenosis Induced by Restrictive Annuloplasty for Ischemic and Functional Mitral Regurgitation.

There are few reports of the determinants of "functional" mitral stenosis in terms of a residual mitral valve (MV) pressure gradient >5 mmHg following restrictive mitral annuloplasty (RMA) or the effect on long-term outcome in patients with functional mitral regurgitation (MR).Methods and Results:Serial cardiac catheterization and echocardiographic studies were performed in 55 patients with functional MR who underwent RMA using a 24/26-mm semi-rigid complete ring. The mean postoperative (1 month) catheter-measured MV gradient was 3.4±1.6 mmHg, which was independently associated with corresponding cardiac output [standardized partial regression coefficient (SPRC)=0.59] and indexed effective orifice area (SPRC=-0.25). Body surface area (BSA) had the greatest contribution to MV gradient (SPRC=0.38), followed by use of a 24-mm ring (SPRC=0.33) and hemodialysis (SPRC=0.26). Receiver-operating characteristic curve analysis demonstrated an optimal BSA cutoff value of 1.86 m2to predict post-MV stenosis (21% for <1.86 m2vs. 86% for ≥1.86 m2, P=0.002). During follow-up (75±32 months), freedom from adverse events did not differ between patients with (n=16) and without (n=39) an MV gradient ≥5 mmHg (log-rank P=0.24). Post-RMA MV gradient was determined not only by the degree of annular reduction but also by patients' hemodynamic factors (e.g., cardiac output). Implantation of a 24/26-mm annuloplasty ring for patients with BSA ≥1.86 m2indicated a high likelihood of post-MV stenosis. However, mild MV stenosis did not adversely affect late outcome after RMA.

Impact of Left Ventricular to Mitral Valve Ring Mismatch on Recurrent Ischemic Mitral Regurgitation After Ring Annuloplasty.

In ischemic mitral regurgitation (IMR), ring annuloplasty is associated with a significant rate of recurrent MR. Ring size is based on intertrigonal distance without consideration of left ventricular (LV) size. However, LV size is an important determinant of mitral valve (MV) leaflet tethering before and after repair. We aimed to determine whether LV-MV ring mismatch (mismatch of LV size relative to ring size) is associated with recurrent MR in patients with IMR after restrictive ring annuloplasty. Patients with moderate or severe IMR from the 2 Cardiothoracic Surgical Trials Network IMR trials who received MV repair were examined at 1 year after surgery. Baseline LV size was assessed by LV end-diastolic dimension and LV end-systolic dimension (LVESd). LV-MV ring mismatch was calculated as the ratio of LV to ring size (LV end-diastolic dimension/ring size and LVESd/ring size). At 1 year after ring annuloplasty, 45 of 214 patients with MV repair (21%) had moderate or greater MR. In univariable logistic regression analysis, larger LVESd (P=0.02) and LVESd/ring size (P=0.007) were associated with recurrent MR. In multivariable models adjusted for age, sex, baseline LV ejection fraction, and severe IMR, only LVESd/ring size (odd ratio per 0.5 increase, 2.20; 95% confidence interval, 1.05-4.62; P=0.038) remained significantly associated with 1-year MR recurrence. LV-MV ring size mismatch is associated with increased risk of MR recurrence. This finding may be helpful in guiding choice of ring size to prevent recurrent MR in patients undergoing MV repair and in identifying patients who may benefit from MV repair with additional subvalvular intervention or MV replacement rather than repair alone. URL:http://clinicaltrials.gov. Unique identifiers: NCT00806988 and NCT00807040.

Is subvalvular repair worthwhile in severe ischemic mitral regurgitation? Subanalysis of the Papillary Muscle Approximation trial

ObjectiveThe symmetry of mitral valve tethering and regional left ventricle wall dysfunction are reported to play a fundamental role in the outcomes and long-term durability of surgical repair in ischemic mitral regurgitation (IMR). We recently demonstrated in a randomized clinical trial (the Papillary Muscle Approximation trial) the superiority of papillary muscle approximation (PMA) in combination with standard restrictive annuloplasty (RA) in severe IMR over annuloplasty alone in terms of adverse left ventricular remodeling and mitral regurgitation (MR) recurrence. This approach, however, failed to produce a survival advantage and was still plagued by a high incidence of reoperation. We therefore performed a subanalysis of the PMA trial on the basis of preoperative parameters to elucidate the value of subvalvular surgery in certain subcategories of patients with the aim of creating a decisional algorithm on the best operative strategy. MethodsWe performed a subanalysis of PMA trial, evaluating 96 patients with severe IMR and eligible for myocardial revascularization randomized to PMA + RA (n = 48) versus RA alone (n = 48) in association with coronary artery bypass grafting. Endpoints included left ventricular remodeling, MR recurrence, overall mortality, reoperation, and a composite cardiac endpoint (cardiac death, stroke, reintervention, hospitalization for heart failure, or New York Heart Association class worsening). Stratification variables were preoperative symmetry of mitral valve tethering and regional wall motion abnormality. ResultsPMA improved ventricular remodeling and recurrence of MR in both preoperative symmetric and asymmetric tethering and in case of inferior wall dyskinesia but did not produce an additional benefit in anterolateral wall dysfunction. ConclusionsPreoperative symmetric and asymmetric tethering and isolated inferior wall dyskinesia are an indication for subvalvular apparatus surgery in IMR.

Are adjunct subvalvular techniques more effective than isolated restrictive annuloplasty for treating ischemic mitral regurgitation?

This review focused on whether subvalvular techniques are more effective than isolated restrictive annuloplasty in addressing ischemic mitral regurgitation (MR). Searching identified 445 papers and, following a selection process, we ended up with 10 articles. Two were propensity-matched studies, four retrospective and four prospective, non-randomized studies. The end points of interest were late recurrence of MR, other early echocardiographic outcomes of mitral function and early mortality. All studies focusing on echocardiographic measurements showed improved results in the groups where subvalvular repair techniques were used. In almost all studies, the recurrence of MR postoperatively was less when subvalvular techniques were used. No difference in early or in-hospital mortality was demonstrated in all four studies that included comparisons. We conclude that subvalvular techniques in combination with annuloplasty are safe and may better address ischemic MR than the use of annuloplasty ring alone.

Immediate and mid-term result of restrictive mitral annuloplasty using a small semi-rigid ring

Though annuloplasty using a properly sized ring has been advocated in degenerative mitral regurgitation, restrictive annuloplasty using a down-sized ring is widely used in ischemic mitral regurgitation. We investigated the outcome of restrictive annuloplasty using a small (24- or 26-mm) ring in mitral regurgitation irrespective of the etiology. Nineteen patients underwent a restrictive annuloplasty using a 24-mm (n = 8) or 26-mm (n = 11) semi-rigid ring. The etiology included degenerative in 13 patients, ischemic in 3, endocarditis in 2, and congenital in 1. Body surface area of the patients implanted with the 24-mm ring was 1.40 ± 0.16 and 1.60 ± 0.18 m(2) for the 26-mm ring. Fifteen patients had 3+ or 4+ mitral regurgitation preoperatively. Two patients were converted to valve replacement for residual mitral regurgitation during the operation. One operative mortality associated with infection was observed. Echocardiogram at 29.4 ± 14.2 months postoperatively demonstrated mitral valve area of 2.0 ± 0.6 cm(2) for 24-mm ring and 2.2 ± 0.5 cm(2) for 26-mm ring with indexed mitral valve area of 1.4 ± 0.4 cm(2)/m(2) for both groups, and no mitral regurgitation more than 2+. Transmitral mean pressure gradient on rest was 4.7 ± 2.1 mmHg at last follow up. New York Heart Association class improved from 2.2 ± 0.7 to 1.2 ± 0.2 after the operation. No late death or reoperation was observed during the follow-up of 31.0 ± 15.0 months. Restrictive mitral annuloplasty using a small ring provided acceptable early and midterm results in patients with body surface area around 1.5 cm(2) without Barlow pathology. Restrictive annuloplasty may be another technical aspect to avoid valve replacement.

Mitral valve repair for ischemic mitral regurgitation: lessons from the Cardiothoracic Surgical Trials Network randomized study.

Approximately 30% to 50% of patients will develop ischemic mitral regurgitation (MR) after a myocardial infarction, which is a result of progressive left ventricular remodeling and dysfunction of the subvalvular apparatus, and portends a poor long-term prognosis. Surgical treatment is centered on mitral valve repair utilizing a restrictive annuloplasty, or valve replacement with preservation of the subvalvular apparatus. In the recent Cardiothoracic Surgical Trials Network (CSTN) study, patients with severe ischemic MR were randomized to mitral valve repair with a restrictive annuloplasty versus chordal-sparing valve replacement, and concomitant coronary artery bypass grafting, if indicated. At 2-year follow-up, mitral valve repair was associated with a significantly higher incidence of moderate or greater recurrent MR and heart failure, with no difference in the indices of left ventricular reverse remodeling, as compared with valve replacement. The current appraisal aims to provide insight into the CSTN trial results, and discusses the evidence supporting a pathophysiologic-guided repair strategy incorporating combined annuloplasty and subvalvular repair techniques to optimize the outcomes of mitral valve repair in ischemic MR.

Feasibility of Restrictive Annuloplasty with Small Size Rigid Ring for Functional Mitral Regurgitation Associated with Poor Left Ventricular Function

Feasibility of Restrictive Annuloplasty with Small Size Rigid Ring for Functional Mitral Regurgitation Associated with Poor Left Ventricular Function

Mitral valve gradient after valve repair of degenerative regurgitation with restrictive annuloplasty

BackgroundsOutcomes of mitral valve repair have been well described for patients with degenerative regurgitation. The hemodynamic effects of repair have not been as well studied, however. We report hemodynamic outcomes in these patients. MethodsWe reviewed 1147 patients who underwent isolated mitral valve repair for degenerative mitral valve regurgitation between January 2004 and December 2013. Baseline characteristics included mean age 58.6 ± 13.4 years, male sex in 792 patients (69.1%), mean ejection fraction of 0.64 ± 0.07, and New York Heart Association class III/IV dyspnea in 215 patients (18.8%). ResultsMitral valve repair involved the posterior leaflet in 764 patients (66.6%), anterior leaflet in 57 patients (5.0%), both leaflets in 260 patients (22.7%), and annuloplasty alone in 66 patients (5.8%). Among the patients who underwent posterior leaflet repair, 713 (93.3%) were treated with our standard technique of triangular leaflet resection/plication and repair with partial posterior band annuloplasty using an unmeasured 63-mm flexible band. Follow-up echocardiography data were obtained in 1138 survivors (99.4%) at 600 ± 880 days. Mild or less valve regurgitation was present at last follow-up in 1030 patients (90.5%). The mean mitral valve gradient was 3.1 ± 1.4 mm Hg in the operating room and 3.5 ± 1.6 mm Hg at the last follow-up (P < .001). The mean mitral valve gradient decreased from the first to the second median time periods (124.5 days) of follow-up (3.7 ± 1.6 mm Hg to 3.3 ± 1.8 mm Hg; P < .001). ConclusionsMitral valve repair for degenerative regurgitation results in a small mitral valve gradient that appears to decrease with time after discharge.

Moderate mitral regurgitation at the time of coronary bypass surgery: repair or leave it?

Moderate ischemic mitral regurgitation (IMR) is a common finding in patients undergoing coronary artery bypass grafting (CABG). In this review, we summarize the current evidence on the optimal management of this condition. In recent years, several randomized clinical trials have assessed the impact of concomitant restrictive mitral annuloplasty at the time of CABG on reverse left ventricular remodeling, IMR reduction and clinical outcomes. Surgical revascularization alone is a conservative strategy that reduces IMR in a significant proportion of patients. Concomitant restrictive annuloplasty provides better relief of mitral regurgitation in the immediate postoperative period, at the cost of increased perioperative morbidity. The only major randomized trial on the issue of moderate IMR published to date showed no difference in reverse left ventricular remodeling at 1 year between these two approaches. There are insufficient data in the literature to support the routine addition of mitral valve repair to CABG in patients with moderate IMR.

Imaging Challenges in Secondary Mitral Regurgitation

Chronic secondary mitral regurgitation (SMR) is a complex entity that is often clinically underappreciated.1 It complicates either ischemic heart disease or dilated cardiomyopathy; its prevalence varies among series but may reach ≤50% in patients with heart failure.2 When present, SMR may exhibit a broad range of severity and confers an adverse prognosis, which is worse with increasing severity of mitral regurgitation (MR).3,4 The management of SMR poses a unique set of challenges, based partly on the complexity of the valve disorder and the still-evolving adoption of the optimal therapeutic approach.5 Noninvasive imaging and, in particular, echocardiography, plays a critical role for the initial and longitudinal assessment, for individual risk stratification and outcome prediction, and for guiding intervention in patients with chronic SMR.6 SMR develops because of a combination of mitral leaflet tethering secondary to left ventricular (LV) dilatation/deformation with papillary displacement/discoordination, annular dilatation/dysfunction, insufficient LV-generated closing forces attributable to reduction of LV contractility, and global LV/papillary muscle dyssynchrony.1,5 Tethering of the mitral leaflets is the principal lesion of SMR and results in restriction of systolic leaflet motion, namely type IIIb of Carpentier’s classification. SMR does not typically occur in global LV dysfunction without tethering. However, once tethering occurs, leaflet closure is further impaired by LV dysfunction because there is decreased force opposing tethering.6–9 The key event in the pathogenesis of SMR is the distortion of normal LV geometry—regional and global LV remodeling—with subsequent apical and lateral displacement of papillary muscles, which, in turn, draws the chordae tendineae away from the line of coaptation.7,8 The extent of LV systolic dysfunction and dilatation is weakly correlated to the degree of SMR unless accompanied by geometric distortion in the region of the papillary muscles.1,9 …

Can isolated annular dilatation cause significant ischemic mitral regurgitation? Another look at the causative mechanisms

This study was to investigate the mechanisms of ischemic mitral regurgitation (IMR) by using a finite element (FE) approach. IMR is a common complication of coronary artery disease; and it usually occurs due to myocardial infarction. The pathophysiological mechanisms of IMR have not been fully understood, much debate remains about the exact contribution of each mechanism to IMR. Two patient-specific FE models of normal mitral valves (MV) were reconstructed from multi-slice computed tomography scans. Different grades of IMR during its pathogenesis were created by perturbation of the normal MV geometry. Effects of annular dilatation and papillary muscle (PM) displacement (both isolated and combined) on the severity of IMR were examined. We observed greater increase in IMR (in terms of regurgitant area and coaptation length) in response to isolated annular dilatation than that caused by isolated PM displacement, while a larger PM displacement resulted in higher PM forces. Annular dilation, combined with PM displacement, was able to significantly increase the severity of IMR and PM forces. Our simulations demonstrated that isolated annular dilatation might be a more important determinant of IMR than isolated PM displacement, which could help explain the clinical observation that annular size reduction by restrictive annuloplasty is generally effective in treating IMR.

Functional impact of transmitral gradients at rest and during exercise after restrictive annuloplasty for ischemic mitral regurgitation

Restrictive mitral valve annuloplasty combined with coronary artery bypass grafting is the treatment of choice for ischemic mitral regurgitation. Postoperative functional mitral stenosis and its potential impact on functional capacity remain the object of debate. The aim of this study was to assess functional and hemodynamic outcome at rest and during exercise in a population with ischemic mitral regurgitation after a standardized restrictive mitral valve annuloplasty. A total of 23 patients with ischemic mitral regurgitation who were previously treated with coronary artery bypass grafting and restrictive mitral valve annuloplasty underwent a semi-supine (bicycle) exercise test with Doppler echocardiography and ergospirometry. The surgical technique was identical in all patients, using a complete semi-rigid ring downsized by 2 sizes after measuring the height of the anterior mitral leaflet, to achieve a coaptation length of at least 8mm. At a mean follow-up of 28±15months, mean transmitral gradients at rest and maximal exercise were 4.4±1.8mm Hg and 8.2±4.2mm Hg, respectively (P<.001). Transmitral gradients did not correlate with exercise capacity (maximal oxygen uptake) or pulmonary artery pressures. Patients with a resting mean gradient of 5mm Hg or greater (n=9) reached a significantly higher maximal oxygen uptake; however, they had a better ejection fraction and cardiac output at rest and reached a higher cardiac output at peak exercise. Transmitral gradients after restrictive mitral valve annuloplasty for ischemic mitral regurgitation did not correlate with functional capacity as measured by maximal oxygen uptake during semi-supine bicycle testing. Functional capacity and transmitral gradients are determined not only by the severity of mitral stenosis but also by hemodynamic factors, such as ejection fraction and cardiac output. Transmitral gradients should be interpreted with respect to patient hemodynamics and not necessarily be considered as detrimental for functional capacity.

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Clinical predictors of long term survival in patients with impaired left ventricle systolic function undergoing mitral valce repair

Objective: Mitral valve repair improves symptoms and reduces myocardial remodeling, however in patients with significantly impaired left ventricle systolic function its impact on long term prognosis remains controversial. The aim of the study was to determine the predictors of long term survival in patients with concomitant systolic heart failure and mitral insufficiency undergoing mitral valve repair. Patients and methods: We included 39 patients (aged 63±12 years, 12 women) with LVEF≤40% (mean 32.3±5.7%, ranged: 15-40%) undergoing mitral valve repair. Patients scheduled for concomitant aortic valve surgery, surgical ventricle restoration or operation due to infective endocarditis were excluded from the analysis. Most patients (n=31, 79%) were significantly symptomatic (NYHA class III or IV), although only one required inotropic support as well as IABP before surgery. In 26 cases (67%) mitral insufficiency had an ischemic etiology. Predicted 30-days mortality as estimated by EuroSCORE II or STS risk models was 3.25 and 4.85% (median), respectively. All patients underwent mitral valve repair (restrictive annuloplasty was done in all cases and an additional intervention on mitral valve, e.g. chordal transfer, posterior leaflet quadrangular resection in 6 cases). Moreover, 18 patients underwent coronary artery bypass grafting, 9 - tricuspidal valve repair and 3 - surgical ablation of atrial arrhythmia. 34 demographic, clinical and echocardiographic parameters were analyzed to identify the independent risk factors for late mortality. Results: During median 3.3 years (IQR: 2-5 years) of follow up 13 patients died. There was one intrahospital death (30-days mortality was 2.5%). The 2- and 5- years cumulative survival was 77 and 66%. Multivariate Cox analysis revealed that the independent predictors for death was COPD (HR 7.95, 95% CI 6.66-9.25) and the need of intense postoperative inotropic support (at least two inotropes for at least 48 hours; HR 7.76, 95% CI 6.52-9.0). Surprisingly, according to the univariate analysis, none of the parameters analyzed (including i.e. left ventricle diameter, renal function, concomitant surgical procedure) except for the mentioned above and the length of stay at the ICU (which in fact is strongly correlated with the postoperative heart failure) differed between survivors and non-survivors. Conclusions: Severe postoperative heart failure that could represent poor reserve of impaired left ventricle predicted worse long term prognosis after mitral valve repair. COPD increased late mortality independently of pulmonary hypertension.

Left atrial strain and strain rate before and following restrictive annuloplasty for ischaemic mitral regurgitation evaluated by two-dimensional speckle tracking echocardiography

Left atrial strain and strain rate before and following restrictive annuloplasty for ischaemic mitral regurgitation evaluated by two-dimensional speckle tracking echocardiography

Percutaneous implantation of a 26 mm Edwards SAPIEN-XT aortic valve prosthesis in a degenerated 30 mm mitral annuloplasty ring

A 80-year-old male presented with New York Heart Association (NYHA) IV functional class and peripheral oedema 6 years after mitral valve (MV) surgery comprising restrictive annuloplasty (St Jude Medical Seguin ring, 30 mm), implantation of neo-chordae and pericardial patch plastic oft the posterior MV leaflet. Echocardiography showed severe MV stenosis [ Panel A , two-dimensional (2D) Doppler trace …

Surgical or percutaneous mitral valve repair for secondary mitral regurgitation: comparison of patient characteristics and clinical outcomes

Corrective surgery for secondary mitral regurgitation (MR) by restrictive annuloplasty has proven beneficial in that it improves New York Heart Association (NYHA) functional class and induces reverse left ventricular remodelling. However, proof of a survival benefit for these patients is still pending. Percutaneous techniques of mitral valve repair (MVR) have become a viable treatment alternative for selected high-risk patients with severe secondary MR. We retrospectively analysed our prospective hospital database of patients with severe secondary MR undergoing either surgical MVR or percutaneous treatment using the MitraClip device. Patient characteristics and 6-month clinical and effectiveness outcomes are reported. From March 2002 through June 2010, 76 patients with secondary MR underwent isolated surgical MVR, while 95 were treated using the MitraClip device at our centre. Patients undergoing MitraClip treatment were significantly older (mean 72.8 ± 8.2 vs 64.5 ± 11.4 years, P < 0.001), had a lower left ventricular ejection fraction (mean 36.2 ± 12.5 vs 42.1 ± 16.2%, P = 0.014) and were generally more high risk, with a significantly higher mean logistic EuroSCORE I compared with surgical candidates (33.7 ± 18.7 vs 10.1 ± 8.7%, P < 0.001). Procedural success was 98.7 (75 of 76) for MVR and 95.8% (91 of 95) for MitraClip treatment (P = 0.383). Thirty-day mortality was 4.2 (4 of 95) and 2.6% (2 of 76; P = 0.557), and the mean grade of residual MR was 1.4 ± 0.8 and 0.2 ± 0.4 (P < 0.001) after MitraClip treatment and surgical MVR, respectively. Six-month survival rates after adjustment for baseline differences were not significantly different in the respective groups (P = 0.642). In our experience, characteristics and risk factors of patients with severe secondary MR undergoing surgery differ significantly from those considered for percutaneous therapy. Surgery was more effective compared with MitraClip in reducing MR. However, a large proportion of patients benefits from percutaneous intervention with sustained MR Grade <2+ and improvement in NYHA functional class at 6 months. MitraClip therapy seems to be an adequate alternative to surgery, especially for elderly patients with reduced left ventricular function and relevant comorbidities. Assessment, treatment and postprocedural care of patients by an interdisciplinary team are of paramount importance for clinical success.