Is MitraClip a major surgery?

No. MitraClip is not open surgery. It is a catheter procedure done through a vein in the groin, with no chest incision and no heart-lung machine. It is still a significant heart procedure. It needs general anaesthesia and guidance with transoesophageal echocardiography, and it should be done by an experienced team. Most patients go home within a few days and recover quickly.

What is the success rate of MitraClip?

In experienced centres, the clip can be placed successfully in most carefully selected patients, and the leak is usually reduced substantially. Success depends heavily on choosing the right candidates and on the anatomy of the valve. Some leak often remains, and more patients need a later procedure than after surgical repair. Your team can explain the likely result in your own case.

Who is not a candidate for MitraClip?

Patients who are good surgical candidates with a repairable valve usually do better with surgery. MitraClip may also be unsuitable when the mitral valve is already narrow, the leaflets are heavily calcified or rheumatic, there is an active infection, or there is a clot inside the heart. Very advanced heart failure can also limit the benefit. A Heart Team assessment decides.

What is the controversy surrounding MitraClip?

The main debate is about who should receive it. Two trials in functional mitral regurgitation, COAPT and MITRA-FR, reached different conclusions. That showed how much patient selection matters. There is also concern that MitraClip is sometimes offered to younger, fit patients who would get a more durable result from surgical repair. In our view, it should complement surgery, not replace it.

MitraClip: what it is, how it works, and who it is really for

MitraClip treats mitral regurgitation through a catheter, without surgery.

In recent years MitraClip has become one of the most talked-about procedures in structural cardiology, and for good reason. For the right patients it is an extraordinary tool that has improved the quality of life of people who would otherwise have had no options.

But as with many new technologies, its popularity has grown faster than clarity about when to use it, and when not to. In this guide I explain what MitraClip is, how it works, and what our clinical position is on its appropriate use.

First, a reminder: what is mitral regurgitation?

The mitral valve separates the left atrium from the left ventricle. When it does not close properly, part of the blood flows backwards with each heartbeat, into the atrium instead of forward into the aorta. That is mitral regurgitation. When it is severe it forces the heart to work above its capacity, which over time weakens it and causes progressive symptoms: breathlessness, fatigue and poor exercise tolerance.

The standard treatment for severe mitral regurgitation is surgery, ideally a repair that keeps the patient’s own valve. But not every patient is a good candidate for surgery, and that is where MitraClip comes in.

What is MitraClip?

MitraClip is a device that reduces mitral regurgitation through a catheter, without open surgery. The technique is known as transcatheter edge-to-edge repair.

The procedure is done under general anaesthesia. Through a vein in the groin, a catheter is advanced to the right side of the heart, crosses the wall between the two atria (a transseptal puncture) and reaches the mitral valve from the left atrium. Guided in real time by transoesophageal echocardiography, one or more small clips are placed to bring the two leaflets together at the point where they leak most. Joining the leaflets lets the valve close better, a little like stitching together two panels of fabric that were not meeting.

The leak is reduced with minimal impact on the patient: no incision in the chest, no heart-lung machine, no stopping the heart. Most patients go home within a few days.

How do we decide who is a candidate?

The assessment for MitraClip is not simple. It depends on several factors:

The anatomy of the valve

Not every leaking valve can be treated with a clip. Where the leak is, the size of the leaflets, how calcified they are and other measurements decide whether a clip can be placed safely and effectively. A three-dimensional transoesophageal echocardiogram is essential.

The cause of the leak

The clip works best in certain mechanisms, such as prolapse with a localised leak in the central part of the valve. In severe functional regurgitation, where the ventricle is enlarged, results vary more.

The function of the left ventricle

Paradoxically, when the ventricle is severely weakened, conventional surgery becomes high-risk and MitraClip may be the most appropriate option. But there is also a point below which even MitraClip offers little benefit.

Overall surgical risk

Validated scores such as the STS score estimate the risk of conventional surgery. When that risk is prohibitive, MitraClip becomes more relevant.

What the clinical trials show

MitraClip has solid scientific backing, but it matters in which patients that benefit was shown.

EVEREST II

Compared MitraClip with surgery in patients at low to moderate surgical risk. MitraClip was safer around the time of the procedure, but surgery was more effective at eliminating the leak, and more patients in the MitraClip group later needed surgery on the valve. Survival at five years was similar.

COAPT

The most important trial for understanding MitraClip today. It studied patients with heart failure and severe functional mitral regurgitation who were already on optimal medication, and showed fewer hospital admissions for heart failure and lower mortality with MitraClip than with medication alone. A similar French trial, MITRA-FR, found no benefit, which is a reminder of how much careful patient selection matters.

The conclusion from the evidence: MitraClip clearly helps patients with severe mitral regurgitation who are not good surgical candidates. In patients who are good surgical candidates, surgery, especially repair, remains superior in the long term.

Our clinical position

I want to be direct about something I see with growing concern. In some centres there is a tendency to offer MitraClip broadly, even to younger patients with good heart function and anatomy that is favourable for surgical repair. Sometimes it is presented as “the modern option” or “the less invasive option”, without explaining clearly that in those patients surgery offers better long-term results.

In our team, we do not consider MitraClip an alternative to surgical mitral repair in patients who are good surgical candidates.

Why? Because a successful surgical repair, especially through a minimally invasive or robotic approach, preserves the patient’s own valve and can last for decades. MitraClip reduces the leak, but in most cases does not eliminate it completely, and its long-term durability is lower than that of a well-performed surgical repair.

For a 55-year-old with severe regurgitation from prolapse and good heart function, offering a clip when the valve can be repaired surgically with excellent results is not, in our opinion, the right decision.

Who is MitraClip really for?

Older patients at high surgical risk, when age, frailty or other illnesses make conventional surgery too risky. MitraClip can relieve symptoms with far less impact.
Patients with a severely weakened ventricle, especially when the regurgitation is functional and secondary to heart failure. MitraClip can improve symptoms and reduce hospital admissions.
Anatomy unsuitable for a durable repair, when the valve is too damaged for a repair likely to last, and replacement is not the ideal option either.
Patients who decline surgery after being fully informed, who, knowing all the options and how their results compare, choose the less invasive procedure even with its lower durability.

Why the assessment must be complete

The decision to perform MitraClip should never be made without a multidisciplinary assessment, a Heart Team, that includes both an interventional cardiologist and a cardiac surgeon. The surgeon is best placed to say whether a patient is or is not a surgical candidate, and what the real risk of an operation would be. Without that perspective, there is a risk that patients who would benefit more from surgery receive a clip for convenience or because of operator preference.

If you have been offered MitraClip and have not been assessed by a cardiac surgeon, it is worth seeking that assessment, or a second opinion, before you decide.

The final message

MitraClip is a powerful tool for the right patients, at the right time, after the right assessment. It is not a universal solution for mitral regurgitation, it does not replace surgery in those who can benefit from it, and it should not be offered as “the modern alternative” without an honest explanation of the differences in long-term results.

If you have mitral regurgitation and want to understand the best option for your case, whether surgery, MitraClip or simply follow-up, bring your studies to a consultation, in person in Guadalajara, Querétaro or Hermosillo, or by video from anywhere.

About the author

Dr. Alejandro Molina Romo is a cardiovascular surgeon practising in Guadalajara, Querétaro and Hermosillo. He trained in cardiothoracic surgery at the Universidad de Guadalajara, completed advanced training in cardiac surgery, minimally invasive surgery, robotic surgery and structural interventions at the University of Montreal, and a fellowship in structural cardiology and TAVI at CHU Bordeaux, France. He performed the first robotic mitral valve repair in the Ángeles Health System and the first robotic heart surgery in Guadalajara.

Medical degree: Universidad Autónoma de Guadalajara, Cédula Profesional 5757260 · Cardiothoracic surgery: Universidad de Guadalajara, Cédula de Especialidad 10768871 · Current certification, Consejo Nacional de Cirugía del Tórax, no. 447

This content is educational and does not constitute personal medical advice. Every cardiac case is unique and requires individual assessment by a specialist medical team. The results described come from published studies and do not guarantee outcomes in any individual case. Always consult the doctor treating you before making decisions about your treatment, especially if you take anticoagulants, antiplatelet drugs or other cardiac medicines.