title: Concept of the central clip: when to use one or two MitraClips®.
abstract: OBJECTIVE
  Percutaneous edge-to-edge mitral valve repair with the MitraClip(®) was shown to be a safe and feasible alternative compared to conventional surgical mitral valve repair. We analyse the concept of the central clip and the predictors for the need of more than one MitraClip(®) in our high-risk surgical population with severe mitral regurgitation (MR).
  
  
  RESULTS
  Patients with severe MR (3 or 4+) and high operative risk (as defined by logistic EuroSCORE) refused for conventional mitral valve repair were considered for MitraClip(®). The procedure was performed under general anaesthesia with transoesophageal echocardiographic (TOE) guidance. Device success was defined as placement of one or more MitraClips(®) with a reduction of MR to ≤2+. Patients were followed up clinically and with TOE at one month and one year. From September 2009 to March 2012, 43 patients with severe MR with a mean age of 74.8±10.7 years (30 males, 13 females; mean logistic EuroSCORE 24.1±11, mean LVEF 47.5±18.5%; mean±SD) were treated. Median follow-up was 385 days (104-630; Q1-Q3). Device implantation success was 93%. All patients were treated following the central clip concept: 52.5% of MR was degenerative in aetiology and 47.5% was functional. The degree of MR was reduced from 3.6±0.4 to 1.4±0.6 (p<0.001); NYHA Class improved from 3.1±0.4 to 1.8±0.7 (p<0.001). Nineteen patients (47.5%) received two or more clips. Vena contracta (p<0.001) and the presence of two broad jets (p<0.001) were correlated with the need for a second clip. The presence of a restricted posterior mitral valve leaflet (PML) was inversely correlated with the need for more than one clip (p=0.02). A cut-off value of ≥7.5 mm for vena contracta predicted the need for a second clip (sensitivity 83%, specificity 90%, p=0.01).
  
  
  CONCLUSIONS
  The central MitraClip(®) concept achieved a significant reduction in the degree of mitral regurgitation in the majority of patients treated. The presence of a broad jet (quantified by a vena contracta greater than 7.5 mm) significantly predicted the need for more than one clip.
authors.affiliation: Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, United Kingdom.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Alegria-Barrero
authors.forename: Pak Hei
authors.initials: PH
authors.lastname: Chan
authors.forename: Nicolas
authors.initials: N
authors.lastname: Foin
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Syrseloudis
authors.forename: Guido
authors.initials: G
authors.lastname: Tavazzi
authors.forename: Susanna
authors.initials: S
authors.lastname: Price
authors.forename: Alistair C
authors.initials: AC
authors.lastname: Lindsay
authors.forename: Alison
authors.initials: A
authors.lastname: Duncan
authors.forename: Neil
authors.initials: N
authors.lastname: Moat
authors.forename: Carlo
authors.initials: C
authors.lastname: Di Mario
authors.forename: Olaf W
authors.initials: OW
authors.lastname: Franzen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001783:Blood Flow Velocity / Q000502:physiology; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D006350:Heart Valve Prosthesis / Q000009:adverse effects; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D006439:Hemodynamics / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology*; D008944:Mitral Valve Insufficiency / Q000503:physiopathology / Q000628:therapy*; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013318:Stroke Volume / Q000502:physiology; D016896:Treatment Outcome