title: Surgical revision after percutaneous mitral valve repair by edge-to-edge device: when the strategy fails in the highest risk surgical population.
abstract: OBJECTIVE
  Percutaneous edge-to-edge devices for non-surgical repair of mitral valve regurgitation are under clinical evaluation in high-risk patients deemed not suitable for conventional surgery. To address guidelines for initial therapy decision, we here report on 13 cases of surgery after failed percutaneous edge-to-edge mitral valve repair or attempted repair, and discuss methodology and prognostic factors for operative outcome in this high-risk situation.
  
  
  METHODS
  Thirteen patients referred to our cardiothoracic unit after failed percutaneous mitral valve repair or attempted repair using the edge-to-edge technique, were treated surgically for mitral valve failure between June 2010 and December 2012. Pathology of mitral valve before and after interventional mitral valve repair (especially prevalent mode of failure) was evaluated and classified for each individual patient by echocardiography and intraoperative direct visualization. Number of implanted edge-to-edge devices were identified. Preoperative risk scores were matched with intraoperative observations and histopathological findings of valve tissue. Postoperative morbidity and mortality were analysed with respect to mitral valve and patient-related data.
  
  
  RESULTS
  Three of 10 patients were referred with severe mitral valve regurgitation/stenosis after initially successful percutaneous edge-to-edge therapy or attempted therapy. In 3 patients, ≥ 2 edge-to-edge devices were implanted leading to very tight edge-to-edge leaflet connection and fibrosis. All patients underwent successful surgical mitral valve replacement and concomitant complete cardiac surgery (CABG, aortic or tricuspid valve surgery, ASD closure and pulmonary vein isolation for atrial fibrillation). The likelihood of repair was reduced with respect to multiple edge-to-edge technology. One device could not be harvested surgically because of embolization. One patient died on the second postoperative day due to sepsis with multiple organ failure. The remaining 12 patients were discharged with excellent valve prosthesis function and followed up to 2 years post-surgery. The current long-term survival rate is 77%.
  
  
  CONCLUSIONS
  Our series demonstrate that highest risk patients can survive mitral valve surgery after failed multiple edge-to-edge interventional mitral valve repair. As long-term results of the MitraClip therapy are pending, we recommend close meshed follow-up of patients treated with the MitraClip device, especially within the first year of the index procedure as delays in salvage management, interventional or surgical, when the index procedure fails may increase morbidity and mortality.
authors: Department of Cardiac Surgery, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Anthony
authors: A
authors: Alozie
authors: Department of Cardiac Surgery, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Bernd
authors: B
authors: Westphal
authors: Department of Cardiology, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Stephan
authors: S
authors: Kische
authors: Department of Cardiac Surgery, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Alexander
authors: A
authors: Kaminski
authors: Department of Cardiology, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Liliya
authors: L
authors: Paranskaya
authors: Department of Cardiology, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Ilkay
authors: I
authors: Bozdag-Turan
authors: Department of Cardiology, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Jasmin
authors: J
authors: Ortak
authors: Department of Anesthesiology and Intensive Care Medicine, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Jochen
authors: J
authors: Schubert
authors: Department of Cardiac Surgery, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany gustav.steinhoff@med.uni-rostock.de.
authors: Gustav
authors: G
authors: Steinhoff
authors: Department of Cardiology, Heart Center Rostock, University Medical Center Rostock, Rostock, Germany.
authors: Hüseyin
authors: H
authors: Ince
mesh_terms: D000368:Aged; D004452:Echocardiography; D005260:Female; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008943:Mitral Valve / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000401:mortality / Q000601:surgery; D008946:Mitral Valve Stenosis / Q000401:mortality / Q000601:surgery; D011788:Quality of Life; D012086:Reoperation; D016879:Salvage Therapy; D013536:Suture Techniques / Q000295:instrumentation*; D017211:Treatment Failure
keywords: Edge-to-edge; MitraClip; Mitral regurgitation; Percutaneous mitral repair; Reoperative surgery