Surgical Revision of Failed Mitraclip Implantation
Takayuki Gyoten, Sören Schenk, Avots Andris, Artur Rajca, Jendrik Puttke, Horst Manus, Alexander Bauer, Oliver Grimmig, Sören Just, Dirk Fritzsche.
Sana Herzzentrum Cottbus, Cottbus, Germany.
Objective: Edge-to-edge repair of mitral valve regurgitation (MR) is increasingly performed by percutaneous MitraClip (Abbott Vascular, Santa Clara, CA, USA) implantations. While residual MR grade 2+ is common after implantation, only limited data is available for those cases that require surgical revision. We report procedural outcomes on 19 patients after failed MitraClip implantation.
Methods: Between 2011 and 2016, 19 patients (74±9 years, 42.1 % male) underwent surgical revision at a median of 54 days (range 1 to 1496 days) after MitraClip implantation. All patients were deemed high-surgical risk with a mean EuroScore of 17,1 (1,9-81,6). Etiology of MR was dilated (n=4), ischemic cardiomyopathy (n=8), dilated and ischemic cardiomyopathy (n=1) or other disease (n=6), and a mean of 2.1 MitraClip devices were implanted. Primary indications for surgery were severe MR (n=16), clip detachment or failed procedural success (n=16), or endocarditis (n=3).
Results: All patients received mitral valve replacement by full sternotomy (n=14) or right-lateral mini-thoracotomy (n=5). Additional procedures included closure of an iatrogenic atrial septal defect (n=7), tricuspid valve repair (n=4), atrial fibrillation ablation (n=3), aortic valve replacement (n=1), and left atrial appendage closure. Thirty-day was 26.3%. Modes of deaths included cardiogenic shock, liver and renal failure, and sepsis. Non-survivors had higher preoperative surgical risk (EuroScore 41.9 vs. 8.2), underwent surgery on an emergent basis (71.8 vs 7.0), and were of septic und cardiogenic shock etiology.
Conclusions: Surgical revision of failed MitraClip implantation is feasible and provides a viable option for this high-risk patient group. Since bailout surgeries are less likely to succeed, we recommend individual risk assessment of MitraClip candidates in heart teams only. Patients with risk factors for unsuccessful MitraClip implantation should be reserved to institutions with an ongoing heart surgery program.
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