Referral for MitraClip Therapy

Your doctors have recommended a mitral valve repair using the MitraClip device to treat your mitral regurgitation. The purpose of this guide is to help you and your family prepare for your procedure at the University of Ottawa Heart Institute. Appendix 1 at the back of this booklet explains some of the terms you might not be familiar with.

About Mitral Regurgitation

Mitral regurgitation (MR) is a condition in which the heart’s mitral valve does not close tightly enough. This lets some of the blood in your heart “regurgitate,” or flow backward, into your heart chambers.

Your heart contains four valves. They are key to the proper flow of blood through the heart. The mitral valve is on the left side of your heart and controls blood flow from the atrium to the ventricle. This valve has two leaflets that open and close to ensure blood travels in only one direction within the heart.

Medical illustration of a heart showing the valves which do not close tightly enough in mitral regurgitation.

In people with MR, the mitral valve doesn’t seal completely and blood leaks backward. As a result, the heart must work harder to push blood through the body. Common symptoms caused by this increased workload include fatigue, shortness of breath, coughing, an irregular heartbeat and worsening heart failure. MR is a progressive disease that can eventually impact your quality of life and make daily activities more difficult.

Side-by-side illustrations showing a normal and a prolapsed heart valve.
Left: Normal, Right: Degenerative MR - Prolapse

Selection Process for MitraClip Therapy

The goal of treatment is to decrease the mitral regurgitation and improve your quality of life. Medications may be prescribed to help reduce the symptoms you experience, but they cannot fix the valve itself.

The current gold standard for treating a severely leaking mitral valve is to perform open heart surgery. The purpose of surgery is to either replace the valve with an artificial one (mitral valve replacement) or repair the existing mitral valve.

In open heart surgery, a heart-lung machine is used to take over the role of your heart while it is being worked on. To repair or replace the mitral valve, the surgeon accesses it in one of two ways. One is through a large incision in the middle of the chest (sternotomy incision).

The other is through a smaller incision in the chest (minimally invasive surgery). In both cases, open heart mitral valve surgery is an effective and-proven way to cure mitral regurgitation, but not all patients are candidates for open heart surgery.

If you are very ill or have many other medical problems, open heart surgery may be considered too high risk. If this is the case, you may be given a referral for a MitraClip procedure. Your eligibility for this procedure will be decided by a specialized team, including a cardiologist experienced in percutaneous (catheter-based) procedures, a cardiac surgeon experienced in valve repair, and a cardiac anesthesiologist experienced in the complex management of patients during these procedures.

Your cardiologist or internist diagnosed you with severe MR after seeing the results of a transthoracic echocardiogram (TTE). This test and your condition triggered a consultation with the MitraClip team. You will need to undergo another test, a transesophageal echocardiogram (TEE), at the Heart Institute to provide the team with the specific measurements of your mitral valve. With this information, the MitraClip team will discuss your case. The purpose of this discussion is to make sure you are getting the right procedure at the right time, along with the best care before and after your procedure.

If you are not accepted for a MitraClip procedure, it means you would not benefit from it. You may be better served by open heart surgery or by having no procedure at all and continuing with your current medical therapy. The next step in your care will be explained to you by one of the physicians on the MitraClip team.

About the MitraClip Procedure

Illustration showing the path of the MitraClip catheter from the groin to the heart.Over the past few years, the MitraClip device has been used in many patients to correct blood flow through the mitral valve without open heart surgery. The MitraClip procedure is performed in a cardiac catheterization lab, not in the cardiac operating room. This procedure is done by use of a catheter that is inserted through a needle hole (percutaneously, or via the skin) in the groin. The catheter—a long, flexible tube—is inserted into a large vein in your groin (femoral vein) and guided to your heart. It is positioned using ultrasound and X-ray images.

Once the tip of the catheter has reached your heart, your mitral valve is assessed using a transesophageal echocardiogram. The TEE also aids in the correct placement of the MitraClip. A tool on the tip of the catheter makes a tiny hole through the upper chambers (atria) of the heart so that the catheter can be inserted and guided to the left side, where the mitral valve is located.

Through the catheter, the MitraClip is then inserted and positioned by ultrasound to the leaking portions of the valve. The clip is attached to the mitral valve leaflets, fastening them firmly together and allowing the valve to close better. It is not uncommon for two MitraClips to be used to fix a severely leaky valve. You will be given general anesthetic so that you will be asleep during the entire procedure.

Image of the Mitraclip device and how it clips to the mitral valve
Left: MitraClip Device Attached To Catheter - Right: MitraClip Closing The Valve

The advantage of this procedure is that it is less invasive than open heart surgery and may reduce the amount of recovery time. The small puncture in your groin, where the catheter is inserted, heals quickly. This is a reasonable alternative to medical treatment (i.e., medications) for patients who are not candidates for open heart surgery (such as the very old and frail, patients with very weak hearts and those who have other non-cardiac conditions involving the lungs, kidneys or brain). Patients who have had previous open heart surgery are also considered for the MitraClip procedure because they may be at higher risk for a re-operation.

On the other hand, the MitraClip procedure is still being studied and evaluated for its long-term effectiveness. Not everyone is a candidate for the MitraClip device. It is used only in a limited group of patients with a certain anatomy and type of leakage. The majority of patients with leaky mitral valves should be treated with traditional surgical methods.