Mitral Valve Repair Techniques Research Articles

Mitral valve repair with resection and non-resection techniques in Barlow's disease: A multi-center study

BackgroundVarious mitral valve (MV) repair techniques are nowadays in use. Non-resection techniques, that rely exclusively on Gore-Tex® neochords and annuloplasty, have been popularized; however, their efficacy in Barlow's disease, characterized by large myxomatous leaflets, is yet unclear. MethodsConsecutive patients undergoing MV repair for Barlow's disease between 2011 and 2019 were selected on the basis of being eligible for resection and non-resection techniques. Study endpoints included overall survival, freedom from MV reintervention and recurrent regurgitation. ResultsOf 209 patients meeting the inclusion criteria, 135 (65%) underwent MV repair with and 74 (35%) without resection. There was one early reoperation due to residual regurgitation (resection group). Mean clinical follow-up duration was 6.1 (IQR 3.9–8.5) years. At 6 years after surgery, there was no difference in overall survival or freedom from MV reintervention. Mean echocardiographic follow-up (95% complete) duration was 3.5 (IQR 2.3–5.8) years. At 6 years, there was no difference in freedom from recurrent regurgitation rate (86.1%, 95% CI 78.5–93.7% vs. 83.0%, 95% CI 71.6–94.4%, P = 0.20) between the groups. Inverse probability-of-treatment weighting adjusted analysis demonstrated no significant difference between groups (HR 0.535, 95% CI 0.212–1.349, P = 0.20). Uni- and multivariable Cox proportional regression analysis did not demonstrate an effect of valve repair technique on the occurrence of recurrent regurgitation. ConclusionsAt mid-term, the clinical and echocardiographic results of valve repair for Barlow's disease were very good and MV reintervention was rarely needed. At this time point, the results of non-resection techniques were comparable to the “gold standard” resection techniques.

CHRONIC INFECTION AND SEVERE MITRAL REGURGITATION: A TRICKY CASE REPORT

Abstract Background Techniques of mitral valve repair has improved in the last decades. Percutaneous approach is now a reliable and safe therapy in those patients with high surgical risk. Of note, the presence of implanted prothesis may increase the risk of endocarditis, especially in those patients experiencing recurrent infection. Case Summary We describe a case of a 75–year–old with medical history of chronic lymphedema. It was characterized by periodical episode (yearly) of cellulitis, with a rapid onset of fever (38.5–39° C), lasting for a few days after paracetamol therapy. Patients had severe mitral valve regurgitation due to prolapse of the posterior leaflet (P2). In December 2022, he had percutaneous edge–to–edge mitral valve. Three months later the patient was admitted to the emergency department of our hospital due to fever without any specific symptoms. The patient was well compensated, normal blood pressure, heart rate and oxygen saturation. He had emocolture which revealed the presence of Staphilococcus lugdunensis. Transesophageal echocardiogram confirmed the presence endocarditis, showing a huge (10x12 mm) vegetation at the level of mitral device (Fig 1 and 2). Patients was then referred to cardiac surgery for urgent mitral valve replacement with mitral bioprothesis (Fig 3). He was treated with ev antibiotic for six weeks after cardiac surgery. Additionally, chronic treatment with amoxicillin 500 mg/day was also prescribed at discharge. After six months follow–up, patients had no signs of endocarditis. Conclusion The management and treatment of chronic infection is of paramount importance to reduce the risk of prothesis infection procedure in patients needing a prothesis implantation. The last European Society of Cardiology guidelines on endocarditis do not provide any recommendation regarding a long–term treatment of patients with high risk of infection (i.e. due to chronic infection) and with an implanted cardiac device/prothesis. We believe this represents an important unmeet need.

Blood cardioplegia reduces intraoperative ventricular fibrillation and transfusion requirements compared to crystalloid cardioplegia in canine mitral valve repair.

Cardioplegic solutions are indispensable for open-heart surgeries, including mitral valve repair (MVR), a potentially curative treatment for myxomatous mitral valve disease in dogs. However, procedural methodologies are not fully established, and complications are yet to be comprehensively understood. Cardioplegic solutions contain various substances to protect the myocardium under temporal cardiac arrest. Nevertheless, ventricular fibrillation (VF) occurs as a common complication after releasing the crossclamp. Based on these backgrounds, the search for optimal cardioplegic solutions in dogs undergoing MVR is an urgent issue. This study aims to evaluate the occurrence of VF in dogs treated with blood cardioplegia (BCP) versus crystalloid cardioplegia (CCP) during MVR. A total of 251 client-owned dogs who underwent MVR from November 2015 to November 2017 were included. We retrospectively assessed the relationship between VF and type of cardioplegia (CCP or BCP) based on surgical records, including VF incidence, transfusion use, crossclamp time, and echocardiographic measurements. Logistic regression analysis showed that the CCP group was associated with the occurrence of VF (OR, 2.378; CI, 1.133-4.992; P = .022). In addition, the CCP group was associated with transfusion use (OR, 2.586; CI, 1.232-5.428, P = .022). There was no difference between the groups for the pre- and postoperative echocardiographic measurements. The BCP group had a lower incidence of VF and less transfusion use than the CCP group. This finding indicates that BCP may be a superior cardioplegic technique for MVR in dogs.

Robotic mitral valve surgery.

Totally endoscopic robotic mitral valve repair is the least invasive surgical therapy for mitral valve disease. Robotic mitral valve surgery demonstrates faster recovery with shorter hospital stays, less morbidity, and equivalent mortality and mid-term durability compared to sternotomy. In this review, we will explore the advantages and disadvantages of robotic mitral valve surgery and consider important technical details of both operative set-up and mitral valve repair techniques. The number of robotic cardiac surgical procedures being performed globally is expected to continue to rise as experience grows with robotic techniques and increasing numbers of cardiac surgeons become proficient with this innovative technology. This will be facilitated by the introduction of newer robotic systems and increasing patient demand.

Modified Fixed Loop-in-Loop Technique in Mitral Valve Repair for Children

Modified Fixed Loop-in-Loop Technique in Mitral Valve Repair for Children

Minimally Invasive Nonresectional Mitral Valve Repair Long-term Results.

We aimed to assess the outcomes of the minimally invasive nonresectional technique over 10 years in patients with severe mitral valve insufficiency. A retrospective analysis of 365 patients undergoing a minimally invasive complete endoscopic mitral valve repair for mitral valve insufficiency was conducted between May 2009 and September 2021. All patients underwent the nonresectional repair approach using artificial neochordae implantation or ring annuloplasty. Clinical and echocardiographic follow-ups were performed. The minimal invasive procedure was successfully performed in all patients. The mean age was 61 ± 11, and 36% were female patients. The surgical success was 99.7%, with no conversion to sternotomy or to mitral valve replacement at 30 days. In 1 case (0.27%), mitral valve related reoperation was performed during the hospital stay. The procedural safety was 92%, with in-hospital mortality in 0.55% (n= 2), stroke in 0.55% (n= 2), and perioperative myocardial infarction in 0.82% (n= 3) patients. The mean follow up was 5.3 ± 2.9 years. Survival at 5 and 10 years was 96% (95% confidence interval [CI], 94%-98%) and 83% (95% CI, 72%-90%). Freedom of myocardial infarction, stroke, and congestive heart failure at 10 years was 95% (95% CI, 88%-98%), 86% (95% CI, 75%-92%), and 93% (95% CI, 89%-96%), respectively. Recurrent mitral valve insufficiency ≥+ 2 was diagnosed in 4.9% of cases. Minimally invasive nonresectional mitral valve repair technique can be performed for severe mitral valve regurgitation with excellent long-term results. The procedure is safe, with minimal risk of reoperation and recurrent mitral valve insufficiency at long term.

Multi-modality imaging evaluation and pre-surgical planning for aortic valve-sparing operations in patients with aortic root aneurysm.

Cardiac computed tomography (CT) and magnetic resonance (CMR) supplement echocardiography in the evaluation of those with aortic root and ascending aortic dilation, determining timing for intervention, guiding pre-surgical planning and post-operative surveillance. The dynamic, three-dimensional complexity of the aortic root and how it relates to the base of the left ventricle must be understood in any surgical approach addressing the aneurysmal aortic root. With improved imaging technology and the importance for proper patient counseling, it is no longer acceptable to enter the operating theater without a detailed blue print of what the problem is, and how best to address it. In addition, reliance on surgical expertise alone for intraoperative evaluation and decision making could be suboptimal due to the unloaded condition of the aortic root and the variance of experience of the surgeons to successfully repair the aortic valve. This is exemplified by the selective surgeons and centers who have the ability to tackle these aortic valve and root pathologies, compared to mitral valve repair techniques that have been codified and are generalizable. This review discusses a multimodality imaging approach in the patient with aortic root aneurysm, focusing on the precision added with pre-surgical CT assessment to guide aortic-valve sparing operations. This precision is afforded with a detailed understanding of the anatomy of the aortic root and underlying support, and its accurate evaluation by standard two- and three-dimensional imaging. Furthermore, we describe the evolving ability to predict the location of ventricular components of the atrioventricular conduction axis with further clinical imaging to personalize surgical strategies.

Selecting the Access and Approach: Resect Versus Respect

Since the late 90s, minimally invasive mitral valve repair (MIMVR) has become a routine technique in cardiac surgery. It is generally defined as a small surgical chest wall incision, which does not involve a complete sternotomy. Using this approach, nearly every surgical technique for mitral valve repair that is performed via full sternotomy can and should also be performed using a mini access approach, as MIMV surgery does not mean accepting compromises.

Looking towards the future: patient-specific computational modeling to optimize outcomes for transcatheter mitral valve repair.

Severe mitral valve regurgitation (MR) is a heart valve disease that progresses to end-stage congestive heart failure and death if left untreated. Surgical repair or replacement of the mitral valve (MV) remains the gold standard for treatment of severe MR, with repair techniques aiming to restore the native geometry of the MV. However, patients with extensive co-morbidities may be ineligible for surgical intervention. With the emergence of transcatheter MV repair (TMVR) treatment paradigms for MR will evolve. The longer-term outcomes of TMVR and its effectiveness compared to surgical repair remain unknown given the differing patient eligibility for either treatment at this time. Advances in computational modeling will elucidate answers to these questions, employing techniques such as finite element method and fluid structure interactions. Use of clinical imaging will permit patient-specific MV models to be created with high accuracy and replicate MV pathophysiology. It is anticipated that TMVR technology will gradually expand to treat lower-risk patient groups, thus pre-procedural computational modeling will play a crucial role guiding clinicians towards the optimal intervention. Additionally, concerted efforts to create MV models will establish atlases of pathologies and biomechanics profiles which could delineate which patient populations would best benefit from specific surgical vs. TMVR options. In this review, we describe recent literature on MV computational modeling, its relevance to MV repair techniques, and future directions for translational application of computational modeling for treatment of MR.

Short and mid-term effects of modified release technique in rheumatic mitral valve repair

ObjectiveRepair or replacement remains debatable in rheumatic heart disease. To regain optimal mean transvalvular pressure gradients and end-diastolic peak flow velocity, the modified release technique combined peeling in the anterior leaflet and separated the shortened chordal. In the end, the short and mid-term outcomes of the modified release technique were evaluated.MethodsWe retrospectively analyzed a series of 128 patients with rheumatic mitral stenosis, from January 2018 to July 2021 in our center. All patients undergoing mitral valve repair were using the modified release technique. The effect of mitral valve repair was evaluated by intraoperative transesophageal echocardiography and postoperative transthoracic echocardiography.ResultsAll the 128 patients successfully repaired the mitral valve. The intraoperative transesophageal echocardiography showed trivial or mild regurgitation. The aortic valve was repaired without obvious regurgitation in 12 cases, 5 cases received an aortic valve replacement, 89 cases underwent tricuspid annuloplasty. There were no blood transfusions in most patients, no deaths nor complications during peri-operation, also, no deaths and adverse events were observed during the follow-up period from 3 to 42 months. During the follow-up, 122 cases had no mitral valve regurgitation and 2 cases of moderate regurgitation, 4 cases of mild to moderate regurgitation. The mean peak flow velocity was 1.2 ± 0.3 m / s, no new-onset stenosis occurred.ConclusionModified release technique is safe and feasible. Its durability is acceptable in the short and mid-term, with no new-onset stenosis during the follow-up.

Anatomical and biometric study of the mitral valve apparatus: application in valve repair surgery

ObjectiveMost mitral valve repair techniques provide excellent surgical results by removing regurgitation, but all of these techniques simultaneously reduce posterior valve mobility. A comprehensive biometric study of the mitral valve apparatus will provide landmarks that would help improve this posterior valve mobility.Materials and methodsThirty one (31) human hearts have been studied, from 14 women and 17 men. The characteristics of the studied sample were analyzed descriptively. The difference in means of the variables between women and men were tested using a Student t test. Correlations between the different measures were determined by simple regression analysis. Mean values are shown with ± 1 standard deviation and the limit of significance was set at 0.05.ResultsThe mean weight of the hearts was 275.3 ± 2.4 g. The anteroposterior diameter of the mitral annulus was 29.3 ± 1.22 mm, the intertrigonal distance was 25.2 ± 3.50 mm and the anterior leaflet to posterior leaflet ratio was 1.9 ± 0.10, the length of the chordae A2 = 19.4 ± 1.15 mm and P2 = 14.5 ± 0.85 mm. The length of the anterior papillary muscle averaged 30.9 ± 7.20 mm and that of the posterior one 30.0 ± 8.75 mm. The comparison of the different values measured between women and men showed no statistically significant difference (p > 0.05). There was no correlation between these different measured values (p > 0.05).ConclusionA perfect knowledge of anatomy and biometry is therefore essential to offer alternative techniques that reproduce the real anatomy and physiology with a complete reconstruction of the mitral valve.

The following video describes our technique of Mitral Valve Repair on a fibrillating heart. We demonstrate our standard setup as well as port placement followed by several steps in preparation for a fibrillatory arrest. The video displays the access to the left atrium followed by neocords creation and ring placement as a reproducible and safe technique.

The following video describes our technique of Mitral Valve Repair on a fibrillating heart. We demonstrate our standard setup as well as port placement followed by several steps in preparation for a fibrillatory arrest. The video displays the access to the left atrium followed by neocords creation and ring placement as a reproducible and safe technique.

New Echocardiographic Parameters Predicting Successful Trans-Ventricular Beating-Heart Mitral Valve Repair with Neochordae at 3 Years: Monocentric Retrospective Study

The NeoChord procedure is an echo-guided trans-ventricular beating-heart mitral valve repair technique to treat degenerative mitral regurgitation (MR) due to prolapse and/or flail. The aim of this study is to analyze echocardiographic images to find pre-operative parameters to predict procedural success (≤moderate MR) at 3-year follow-up. Seventy-two consecutive patients with severe MR underwent the NeoChord procedure between 2015 and 2021. MV pre-operative morphological parameters were assessed using 3D transesophageal echocardiography with dedicated software (QLAB, Philips). Three patients died during their hospitalization. The remaining 69 patients were retrospectively analyzed. At follow-up, MR > moderate was found in 17 patients (24.6%). In the univariate analysis, end-systolic annulus area (12.5 ± 2.5 vs. 14.1 ± 2.6 cm2; p = 0.038), end-systolic annulus circumference (13.2 ± 1.2 vs. 14 ± 1.3 cm; p = 0.042), indexed left atrial volume (59 ± 17 vs. 76 ± 7 mL/m2; p = 0.041), and AF (25% vs. 53%; p = 0.042) were lower in the 52 patients with ≤ MR compared to those with > moderate MR. Annular dysfunction parameters were the best predictors of procedural success: 3D early-systolic annulus area (AUC 0.74; p = 0.004), 3D early-systolic annulus circumference (AUC 0.75; p = 0.003), and 3D annulus area fractional change (AUC 0.73; p = 0.035). Patient selection relying on 3D dynamic and static MA dimensions may improve the maintenance of procedural success at follow-up.

Robotic vs other surgery techniques for mitral valve repair and/or replacement: A systematic review and meta-analysis

ObjectiveMitral valve repair or replacement (MVr/R) are procedures that aim to correct mitral regurgitation. The three techniques, namely conventional, minimally invasive, and robotic each present their advantages and setbacks. Previous studies had compared each technique with the other but mostly focused on two techniques. In this systematic review and meta-analysis, we attempt to compare all three techniques, to provide a reference for the clinical selection of the best surgical scheme. MethodsThe literature search was performed in databases including PubMed, Scopus, Google Scholar, EBSCOHost, Wiley, ProQuest, and Embase, up to June 1st, 2022. Critical appraisal of studies was performed using Newcastle Ottawa Scale converted by Agency for Healthcare Research and Quality (AHRQ). We used bayesian network meta-analysis and conventional meta-analysis (random effects model) to rank and analyze pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). Forest plots of pooled effect estimates comparing each treatment and ranking panel using Surface Under the Cumulative Ranking (SUCRA) were used for the intervention measures. ResultsA total of 18 studies with 60,331 patients were included in this systematic review and meta-analysis. Hospital stay was significantly lower in the group with robotic procedure compared to the conventional interventions in terms of ICU stay and overall length of stay. The mean difference of length of hospital stay days of the conventional group was 2.27 (1.31–3.30) days and of the minimally invasive −0.364 (−2.31–1.53) days compared to the robotic group. The robotic procedure was associated with longer cross-clamp and cardiopulmonary bypass (CPB) times. Nevertheless, the robotic procedure was associated with lower infection (OR = 0.60 [95% CI 0.50–0.73)] rates and in-hospital mortality compared to conventional techniques (OR=0.53 [95% CI 0.40–0.70)] but not the minimally invasive techniques (OR = 1.74 [95% CI 0.48–6.31]). ConclusionRobotic surgery showed more favorable surgical outcomes, including hospital stay, post-operational complications and in-hospital mortality, although it was associated with longer cross-clamp time and CPB time compared to other interventions. However, its high cost is a difficult consideration for its widespread clinical implementation.

Multimodality Echocardiographic Imaging for a Novel Transcatheter Native Mitral Valve Replacement Procedure

ABSTRACT Transcatheter native mitral valve replacement (TMVR) is a novel procedure that has the potential to overcome some of the current limitations associated with the transcatheter edge-to-edge mitral valve (MV) repair technique. The aim of this study was to describe the key steps in periprocedural echocardiographic guidance of TMVR with the Tendyne system, emphasizing potential caveats and areas of difficulty. The imaging pathway can be schematized in four fundamental steps: baseline evaluation of mitral regurgitation (MR), preprocedural screening and planning, intraprocedural guidance, and follow-up. Baseline evaluation of MR in TMVR includes the guidelines-recommended imaging pathway of MR assessment. A dedicated preprocedure cardiac multimodality imaging screening and planning for TMVR is able to determine patient eligibility according to the anatomic characteristics and measurements, provide information for appropriate valve sizing, and detect features that can predispose to potential hazard or complications. Cardiac computed tomography and two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) are the main actors in this phase. The road map for intraprocedural TMVR guidance includes the following: (1) apical access assessment: 2D TEE assessment of the site for optimal left ventricular apical access as planned by the preprocedural computed tomography; (2) support for catheter and sheath localization, trajectory, and positioning; and (3) valve positioning and radial orientation. Thereafter, the prosthesis is withdrawn toward the left ventricle and deployed intra-annularly. Post-deployment includes assessment for correct clocking and hemodynamics, perivalvular leakage, and left ventricular outflow tract obstruction. Two-dimensional and 3D TEE and fluoroscopy provide intraprocedural guidance. The follow-up of the Tendyne device includes the guidelines-recommended imaging pathway of bioprosthesis. Knowledge of multimodality imaging use is key for the interventional imagers and crucial in the success of the procedure.

MitraClip: a review of its current status and future perspectives.

Mitral regurgitation (MR), among the most common valvular heart diseases, is closely associated with heart failure and worse clinical outcomes. Surgical repair or replacement as an intervention for MR is deemed too high risk in patients who are elderly or have multiple comorbidities; thus, nearly half of all patients with severe symptomatic MR are not referred for surgical therapy. MitraClip, a transcatheter mitral valve repair system for MR that mimics the Alfieri surgical edge-to-edge technique for mitral valve repair, was developed in the late 1990s. After clinical trials demonstrated its safety and efficacy, it received approval for clinical use, particularly for aging and inoperable or high-risk patients for heart surgery in Europe, the US, and Japan. Since the start of its clinical use, randomized clinical trials (RCTs) have optimized patient selection, and the latest generation MitraClip can increase procedural success, even in patients with challenging mitral valve anatomy. Therefore, here, we review evidence from clinical trials and RCTs and discuss optical patient selection and future perspectives for the MitraClip.

Robotic Mitral Valve Surgery.

Growing interest in minimalizing surgical trauma during heart procedures stimulated the development of robotic mitral valve surgery in the late 1990s. Initially, the new technology was slowly adopted in clinical practice. However, following encouraging results by teams that adopted robotic heart surgery early on, a growing interest in implementation of robotic mitral valve surgery has emerged. Of importance are the technical developments and possibilities that accompany robotic surgery. Robotic arms feature unique characteristics, allowing unparalleled range of motion and allowing complex mitral valve repair techniques to be performed without limitations related to limited surgical incisions. High-quality three-dimensional vision effectively compensates for the lack of tactile feedback. Several technical solutions have been developed to facilitate mitral valve repair in minimal invasive setting, including chordal guiding systems, now available with various annuloplasty rings. On the other hand, precise vision and movements allows accurate determination of the length of implanted neochordae, facilitating precise determination of the length of implanted neochords even without the use of chordal-guiding systems. With robotic mitral valve surgery, leaflet resection techniques can be performed without limitations, ensuring that no compromises of the surgical strategy are made. Nevertheless, careful preoperative planning with appropriate work-up and imaging is of utmost importance to prevent complications. Moreover, the drawbacks of the initial learning curve and higher procedural costs are counterbalanced by less surgical trauma, lower utilization of blood products, and faster patient recovery. Robotic mitral valve surgery is still a young field and evolving technology that is bound to become an important tool in the toolbox of surgical mitral valve approaches.

Endoscopic mitral valve repair utilizing cavitron ultrasonic surgical aspirator for active endocarditis.

Mitral valve repair for endocarditis in an acute setting is still challenging due to difficulties in debriding friable tissue and in leaving enough non-infected tissue for reconstruction. Endoscopic approaches for complex mitral valve procedures via a minimally invasive approach have been reported from high-volume programs. However, the role of endoscopic mitral valve surgery for acute infective endocarditis has not been clearly defined. We report our technique of endoscopic mitral valve repair using the cavitron ultrasonic surgical aspirator system for active endocarditis. The cavitron ultrasonic surgical aspirator with a low power setting provides enough debridement of the infective tissue and leaves healthy tissue adequate for repair under a totally endoscopic vision.

A morphofunctional analysis of the regurgitant mitral valve as a guide to repair: Another point of view.

Based on Carpentier's classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morphofunctional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.

Mitral valve surgery after failed MitraClip-Operation for the inoperable?

Percutaneous edge-to-edge mitral valve repair technique (MitraClip) is a widely used treatment for mitral regurgitation (MR) in patients assessed with high surgical risk or inoperability. Only limited experiences with this highest-risk patient population exist. Procedural failure for MitraClip or recurrent MR is a strong predictor of 1-year mortality. Open mitral valve surgery constitutes the last bailout for patients within this cohort. This retrospective single-center cohort study analyzed 17 mitral valve surgery patients after failed MitraClip. We, therefore, analyzed a high-risk patient population (EuroSCOREII = 10 ± 2.0) with persistent mitral valve regurgitation, which was mainly caused by detachment or dislocation of the MitraClip. Symptomatic patients with failed MitraClip need a convenient operation (mean time to mitral valve surgery = 23 ± 44 days). The patient's collective showed many complex reoperations with the need for concomitant surgery. Considering the high-risk patient population, we showed an average 30-day all-cause mortality (18%, n = 3) accompanied by typical postoperative complications related to prolonged mechanical ventilation (44 ± 48 h) and ICU stay (11 ± 11 days), reflecting high-risk patients. Further, excellent valve-related outcomes were shown regarding adverse cardiac events (valve-related mortality 6%, n = 1) and postoperative echocardiographic results (moderate or severe paravalvular leak 6%, n = 1). Failure of MitraClip represents a challenging situation limited by high-risk profiles of patients and limits the possibility of surgical valve repair, shown by a high rate of mitral valve replacement (94%, n = 16). Secondary surgery was associated with moderate 30-day and postdischarge outcomes. Therefore, a careful evaluation of patients undergoing MitraClip is of paramount importance.