Real World Outcomes Of The Mitraclip Procedure At A Single Institution
Joshua L. Manghelli, Daniel I. Carter, Ali J. Khiabani, Farah N. Musharbash, Hersh S. Maniar, Alan Zajarias, John M. Lasala, Marc A. Sintek, Marc R. Moon, Ralph J. Damiano, Spencer J. Melby.
Washington University in St. Louis, St. Louis, MO, USA.
BACKGROUND Approximately 50% of patients with severe symptomatic MR are deemed too high risk for surgery. The Mitraclip procedure has become a viable option for some of these patients, but others may not benefit despite the procedure being minimally invasive. Our goal was to identify risk factors for failure to identify patients that fail the procedure.METHODS A retrospective study of all patients undergoing the MitraClip procedure at a single institution was performed. Baseline characteristics, perioperative outcomes and follow-up echocardiographic and clinical outcomes were examined. Failure was defined as 30-day mortality, reoperation for valve, follow-up 3+/4+ MR, or NYHA III/IV symptoms. Predictors of mortality and failure were determined using multivariable regression analysis. RESULTSFifty patients underwent the MitraClip procedure during the four year period. The average age was 83, mean EuroSCORE II was 7.4%, 88% (44/50) were in NYHA III/IV symptoms , 86% (43/50) had 4+ MR, and 72% (36/50) had degenerative mitral disease etiology. Perioperatively, complications included stroke (3/50, 6%), urgent sternotomy for bleeding (1/50, 2%), cardiac arrest (1/50, 2%), and postop atrial fibrillation (3/50, 6%). Median length of stay was 3 days. Follow-up outcomes showed readmission within 30 days of 16% (8/50), 30 day mortality of 4% (2/50). Echocardiographic follow-up (median follow-up 43[26,392]) showed 68% (34/50) had either 2+ or less mitral regurgitation. 60% (24/40) had NYHA I/II symptoms at last followup. Twenty-seven patients (54%) met the criteria for failure. Predictors of failure were preoperative NYHA III or IV (p 0.049, OR 12.489). Predictors of mortality were higher EURO II score (p=0.042, HR 1.098) and previous cardiac surgery (p=0.013, HR 3.848). Survival at 1, 2, and 3 years was 75%, 63%, and 42%, respectively (Figure).CONCLUSIONSPatients presenting for the MitraClip procedure are a high-risk and complex group. The MitraClip procedure is feasible to offer patients that are deemed too high risk to undergo surgery, with the understanding that about half will have significant improvement in clinical and echocardiographic outcomes. Unfortunately those with the highest risk of failure are those that stand to benefit most from the procedure. Development of better alternative treatments are needed.
Legend: Figure: Kaplan Meijer analysis of patients undergoing the MitraClip procedure
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