title: Impact of MitraClip™ therapy on secondary mitral valve surgery in patients at high surgical risk.
abstract: OBJECTIVE
  Conventional or minimally invasive surgical mitral valve repair (MVR) is the gold-standard treatment for severe mitral regurgitation (MR) of any etiology. Given its good safety profile, trans-catheter MVR with the MitraClip™ device is used increasingly for high-risk or inoperable patients. We report our experience with failed MitraClip™ therapy and its impact on subsequent surgical strategies, such as the feasibility of MVR in high-risk patients.
  
  
  METHODS
  During a follow-up of 344 ± 227 days from the first 215 consecutive patients treated with the MitraClip™ device, six patients required surgical re-intervention due to failed repair (n = 3) or recurrent severe MR (n = 3) at 35.8 ± 47.7 (range 0-117) days after trans-catheter MVR. Feasibility of secondary surgical MVR was assessed with regard to prior clip therapy.
  
  
  RESULTS
  In three patients, secondary surgical MVR was successfully performed following the surgical strategy deemed optimal before trans-catheter treatment. Injury of the mitral leaflets caused by prior clip treatment was present in three other patients and influenced the surgical strategy toward more complex surgical techniques in one case and MV replacement in two others. One patient died 6 days after MV replacement. All other patients are alive with adequate valve function at the latest follow-up of 12.4 ± 7.4 months (range 4-22).
  
  
  CONCLUSIONS
  Secondary surgical MVR was feasible in some patients after prior clip treatment, but led to valve replacement in others. At present, patient selection criteria for trans-catheter MVR should not be expanded toward more healthy patients, as primary trans-catheter MVR may complicate secondary surgery in certain cases and may even preclude reconstructive valve surgery.
authors.affiliation: Department of Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistr 52, D-20246 Hamburg, Germany. lconradi@uke.de
authors.forename: Lenard
authors.initials: L
authors.lastname: Conradi
authors.forename: Hendrik
authors.initials: H
authors.lastname: Treede
authors.forename: Olaf
authors.initials: O
authors.lastname: Franzen
authors.forename: Moritz
authors.initials: M
authors.lastname: Seiffert
authors.forename: Stephan
authors.initials: S
authors.lastname: Baldus
authors.forename: Johannes
authors.initials: J
authors.lastname: Schirmer
authors.forename: Thomas
authors.initials: T
authors.lastname: Meinertz
authors.forename: Hermann
authors.initials: H
authors.lastname: Reichenspurner
mesh_terms: D000368:Aged; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D019736:Prostheses and Implants; D011475:Prosthesis Failure; D012008:Recurrence; D012086:Reoperation / Q000379:methods