Does implantation of a single clip provide reliable durability after transcatheter mitral repair?
OBJECTIVE
A single MitraClip implant is often considered enough to achieve adequate mitral regurgitation (MR) reduction. The aim of this study was to compare MR recurrence in patients with an initial optimal result treated with a single clip versus those treated with two clips.


METHODS
From October 2008 to May 2016, 322 patients were treated with the MitraClip procedure at our institution. We retrospectively selected all patients treated for functional MR (FMR) and degenerative MR (DMR) aetiologies with residual MR ≤1+, excluding patients who required >2 clips. FMR and DMR were analysed separately.


RESULTS
In FMR, a single clip was used in 45 patients and 2 clips in 99 patients. The single clip group had smaller coaptation depth (1.1 ± 0.3 vs 1.3 ± 0.3 mm, P  = 0.022) and jet extension (10.5 ± 2.1 vs 13.0 ± 3.6 mm, P  = 0.026) as well as left ventricular end-diastolic diameter (64.4 ± 7.3 vs 69.0 ± 7.9 mm, P  = 0.001). Freedom from MR ≥ 3+ after 4 years was 71.9 ± 8.9% in patients receiving a single clip vs 88.0 ± 5.2% in those receiving 2 clips, single clip use being an independent predictor of MR recurrence (HR 3.48, CI 1.24-9.81, P  = 0.018). In DMR, a single clip was deployed in 24 patients and 2 clips in 30 patients. The single clip group had a smaller flail gap (3.6 ± 0.7 vs 6.8 ± 2.5, P  = 0.002). Freedom from MR ≥ 3+ after 2 years was 82.5 ± 8% in patients with a single clip vs 100% in those with 2 clips, P  = 0.014. The residual mitral area was reduced in patients with 2 clips compared with those with single clip, both in FMR ( P  = 0.015) and DMR ( P  = 0.039), but it was not associated with increased death rate during the follow-up period (all P  > 0.05).


CONCLUSIONS
Despite favourable anatomical characteristics and an optimal initial result, implantation of a single clip was associated with an increased recurrence of MR compared with that of 2 clips, both in FMR and in DMR. Caution should be exercised with the implantation of a single clip.
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Nicola
N
Buzzatti
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Paolo
P
Denti
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Giovanni
G
La Canna
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Davide
D
Schiavi
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Luca
L
Vicentini
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Iside Stella
IS
Scarfò
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Ilaria
I
Caso
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Michele
M
De Bonis
Department of Cardiac Surgery, San Raffaele Scientific Institute, Milan, Italy.
Ottavio
O
Alfieri
D000368:Aged; D006328:Cardiac Catheterization / Q000379:methods*; D004452:Echocardiography; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000295:instrumentation*; D006801:Humans; D008297:Male; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D008944:Mitral Valve Insufficiency / Q000175:diagnosis / Q000601:surgery*; D012189:Retrospective Studies; D013525:Surgical Instruments; D013997:Time Factors; D016896:Treatment Outcome
MitraClip; Repair; Transcatheter