MitraClip and Tricuspid Valve Interventions - Minimally Invasive Valve Treatment

What is Heart Valve Regurgitation?

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Heart valves are structures that ensure one-way blood flow between heart chambers and between the heart and major vessels. Valve regurgitation means the valve does not close completely, causing blood to leak backward. This creates extra load on the heart and can lead to heart failure over time.

Mitral Valve Regurgitation

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The mitral valve is located between the left atrium and left ventricle. Mitral regurgitation is one of the most common valve diseases and occurs in two main types:

Primary (Organic) Mitral Regurgitation:

• Degeneration of valve leaflets
• Mitral valve prolapse
• Chordae tendineae rupture
• Rheumatic valve disease
• Infective endocarditis

Secondary (Functional) Mitral Regurgitation:

• Left ventricular dilatation due to heart failure
• Post-ischemic heart disease
• Dilated cardiomyopathy
• Valve structure normal but geometry distorted

Tricuspid Valve Regurgitation

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The tricuspid valve is the valve between the right atrium and right ventricle. Tricuspid regurgitation is usually secondary and develops due to other heart diseases:

Secondary Tricuspid Regurgitation:

• Due to left heart valve diseases
• Pulmonary hypertension
• Right ventricular dilatation
• Atrial fibrillation

Primary Tricuspid Regurgitation:

• Rheumatic disease
• Carcinoid syndrome
• Trauma
• Due to pacemaker leads
• Congenital anomalies

Symptoms of Valve Regurgitation

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Symptoms of valve regurgitation vary depending on disease severity and which valve is affected.

Mitral Regurgitation Symptoms

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• Shortness of breath: Especially with exertion and when lying down
• Fatigue: Unusual weakness and energy loss
• Palpitations: Irregular or rapid heartbeat
• Edema: Leg swelling
• Orthopnea: Shortness of breath when lying down
• Paroxysmal nocturnal dyspnea: Waking up at night with shortness of breath

Tricuspid Regurgitation Symptoms

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• Peripheral edema: Prominent swelling in legs and ankles
• Ascites: Fluid accumulation in abdomen
• Hepatomegaly: Liver enlargement
• Jugular vein distension: Fullness in neck veins
• Right upper quadrant pain: Due to liver congestion
• Fatigue and weakness: Due to low cardiac output

What is MitraClip?

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MitraClip is a revolutionary device that enables catheter-based treatment of mitral valve regurgitation. First used in 2003, this method has now been applied to tens of thousands of patients worldwide.

Working Principle of MitraClip

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MitraClip improves valve closure by holding the anterior and posterior leaflets of the mitral valve together. This technique is the catheter version of the surgical technique developed by Alfieri in the 1960s.

MitraClip System Components:

• Clip device: Made of cobalt-chromium alloy, 4 mm wide
• Guide catheter: For access to left atrium
• Steerable catheter: For clip positioning
• Delivery system: Clip placement mechanism

Advantages of MitraClip

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Advantages Over Open-Heart Surgery:

• No chest opening, no sternotomy
• No heart-lung machine required
• Short hospital stay (1-3 days vs 7-10 days)
• Rapid recovery and return to normal
• Low complication risk
• Can be safely performed in high-risk patients
• Can be repeated if necessary
• Does not eliminate future surgical option

MitraClip Indications

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MitraClip is not performed on all mitral regurgitation patients. Patient selection is very important and should be evaluated by a multidisciplinary heart team.

Primary Mitral Regurgitation

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Suitable Patients:

• Severe symptomatic mitral regurgitation (3+ or 4+)
• High surgical risk (STS score ≥8% or)
• High-risk assessment by heart team
• Suitable valve anatomy

Anatomic Criteria:

• Adequate leaflet length (≥10 mm)
• Coaptation depth <11 mm
• Flail width <15 mm
• Minimal calcification

Secondary Mitral Regurgitation

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Suitable Patients:

• Functional mitral regurgitation (2+ or greater)
• Heart failure symptoms (NYHA II-IV)
• Symptoms despite optimal medical therapy
• Left ventricular ejection fraction 20-50%
• Left ventricular end-systolic diameter <70 mm

Contraindications

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Absolute Contraindications:

• Rheumatic mitral stenosis
• Active endocarditis
• Intracardiac thrombus
• Severe mitral annular calcification

Relative Contraindications:

• Very advanced heart failure (NYHA IV, inotropic support)
• Severe right heart failure
• Severe pulmonary hypertension
• Unsuitable anatomic features

Pre-MitraClip Evaluation

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A comprehensive evaluation is performed before MitraClip procedure. This evaluation determines whether the patient is suitable for the procedure and meets anatomic criteria.

Imaging Methods

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Transthoracic Echocardiography (TTE):

• Severity of mitral regurgitation
• Left ventricular function and dimensions
• Pulmonary artery pressure
• Concomitant valve diseases

Transesophageal Echocardiography (TEE):

• Detailed valve anatomy
• 3D imaging for leaflet assessment
• Coaptation point and depth
• Flail segment localization
• Left atrial appendage thrombus screening

Cardiac Computed Tomography (CT):

• Additional anatomic information when needed
• Vascular access assessment
• Coronary artery anatomy

Additional Evaluations

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Coronary Angiography:

• Screening for concomitant coronary artery disease
• Revascularization planning if needed

Right Heart Catheterization:

• Pulmonary artery pressures
• Cardiac output measurement
• Pulmonary vascular resistance

Laboratory Tests:

• Complete blood count
• Kidney and liver functions
• Coagulation parameters
• BNP/NT-proBNP levels

General Condition Assessment:

• Functional capacity (6-minute walk test)
• Frailty assessment
• Comorbidities
• Life expectancy

How is MitraClip Procedure Performed?

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MitraClip procedure is performed by an experienced interventional cardiology team in a hybrid operating room or catheterization laboratory.

Pre-Procedure Preparation

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• Fasting: 6-8 hours before procedure
• Medications: Blood thinners stopped with bridge therapy
• Anesthesia assessment: Suitability for general anesthesia
• Consent: Detailed information and written consent

Procedure Steps

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1. Anesthesia and Monitoring

• General anesthesia administered
• TEE probe placed
• Hemodynamic monitoring

2. Vascular Access

• Right femoral vein puncture
• Guide wire advancement
• Sheath placement

3. Transseptal Puncture

• Passage from right atrium to left atrium
• Atrial septum puncture with needle
• Optimal puncture site selection (superior-posterior)

4. Guide Catheter Placement

• 24F guide catheter advanced to left atrium
• Steerable catheter passed through

5. MitraClip System Preparation

• Clip device advanced through guide catheter
• Positioned over mitral valve
• Optimal position achieved with TEE guidance

6. Leaflet Capture

• Clip opened and placed between leaflets
• Anterior leaflet captured
• Posterior leaflet captured
• Both leaflets confirmed in clip

7. Result Evaluation

• Mitral regurgitation degree checked with TEE
• Mitral stenosis formation assessed
• Transmitral gradient measured

8. Clip Release or Repositioning

• Clip released if result satisfactory
• Clip repositioned if inadequate
• Additional clip placed if needed (average 1-2 clips)

9. Procedure Completion

• All catheters removed
• Femoral vein hemostasis achieved
• Patient taken to recovery room

Procedure Duration and Hospital Stay

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• Procedure duration: 2-4 hours (varies with experience)
• Intensive care: 24-hour monitoring
• Hospital stay: 1-3 days (uncomplicated cases)
• Discharge criteria: Stable hemodynamics, no complications, successful mobilization

Tricuspid Valve Interventions

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Tricuspid regurgitation treatment has been a neglected area for many years. However, catheter methods developed in recent years offer hope to patients at high surgical risk.

Tricuspid Regurgitation Treatment Options

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Medical Treatment:

• Diuretics (for fluid removal)
• Sodium restriction
• Treatment of underlying disease
• Heart failure medication optimization

Surgical Treatment:

• Tricuspid valve repair (annuloplasty)
• Tricuspid valve replacement
• Usually performed with left heart surgery
• Isolated tricuspid surgery is high risk

Transcatheter Tricuspid Interventions

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Various catheter methods have been developed for tricuspid regurgitation:

TriClip (Abbott):

• Tricuspid valve version of MitraClip
• Edge-to-edge repair principle
• CE approved, FDA approval process
• Early results promising

PASCAL (Edwards Lifesciences):

• Wide capture area
• Spacer technology
• Can be used for both mitral and tricuspid

Cardioband (Edwards Lifesciences):

• Annulus reconstruction
• Ring-like implant
• Reduces annulus size

Other Developing Technologies:

• Tricinch
• Trialign
• Forma
• Valve replacement systems (EVOQUE, Intrepid)

Tricuspid Intervention Indications

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Suitable Patients:

• Severe symptomatic tricuspid regurgitation
• Symptoms despite medical therapy
• High surgical risk
• Suitable anatomic features
• Life expectancy >1 year

Evaluation:

• Detailed echocardiography
• Right ventricular function
• Pulmonary artery pressures
• Liver functions
• General condition assessment

MitraClip and Tricuspid Intervention Outcomes

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MitraClip Clinical Outcomes

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COAPT Study (Secondary MR):

• 47% reduction in hospitalizations
• 38% reduction in mortality (2 years)
• Significant improvement in quality of life
• Increase in functional capacity

EVEREST II Study (Primary MR):

• 80-90% technical success
• Symptom control as effective as surgery
• Lower complication risk
• Shorter hospital stay

Real-World Data:

• Over 100,000 patients treated
• 95%+ success in experienced centers
• Long-term durability proven
• Sustained quality of life improvement

Tricuspid Intervention Early Results

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TriClip Studies:

• 70-80% technical success
• ≥1 grade reduction in tricuspid regurgitation
• Symptom improvement
• Increase in 6-minute walk distance
• Quality of life improvement

Long-Term Data:

• Limited long-term data yet
• Early results promising
• Randomized trials ongoing

Complications and Risks

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MitraClip Complications

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Major Complications (<5%):

• Clip detachment or embolization
• Severe mitral stenosis formation
• Cardiac tamponade
• Stroke
• Vascular complications
• Death (<1%)

Minor Complications:

• Atrial septal defect (usually small and clinically insignificant)
• Transient arrhythmia
• Bleeding
• Infection
• Kidney function impairment

Tricuspid Intervention Complications

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• Clip/device detachment
• Tricuspid stenosis
• Right ventricular injury
• Pericardial effusion
• Vascular complications

Post-Procedure Care and Follow-up

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Hospital Period

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First 24 Hours:

• Intensive care monitoring
• Hemodynamic stability check
• Echocardiography control
• Early mobilization

Before Discharge:

• Control echocardiography
• Medication adjustment
• Patient education
• Follow-up planning

After Discharge

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Medication Therapy:

• Anticoagulation: First 3-6 months (aspirin + clopidogrel)
• Heart failure medication optimization
• ACE inhibitors/ARB/ARNI
• Beta blockers
• Mineralocorticoid receptor antagonists
• SGLT2 inhibitors
• Diuretics (if needed)

Lifestyle Recommendations:

• Salt restriction (2-3 grams/day)
• Fluid restriction (if needed)
• Regular weight monitoring
• Gradual activity increase
• Smoking and alcohol cessation

Follow-up Program:

• 1st month: Clinical evaluation and echocardiography
• 3rd month: Control examination
• 6th month: Detailed evaluation
• Thereafter: Follow-up every 6-12 months

Physical Activity and Exercise

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First Week:

• Light walking
• Daily activities
• Avoid heavy lifting

2-4 Weeks:

• Gradual exercise increase
• Moderate walking
• Stair climbing

After 4-6 Weeks:

• Return to normal activities
• Cardiac rehabilitation program
• Regular exercise routine

Cardiac Rehabilitation

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Participation in cardiac rehabilitation program is recommended after MitraClip and tricuspid intervention:

Rehabilitation Components:

• Supervised exercise program
• Nutritional counseling
• Psychological support
• Risk factor management
• Patient education

Benefits:

• Increased functional capacity
• Quality of life improvement
• Reduced hospitalizations
• Reduced mortality
• Increased confidence

Frequently Asked Questions (FAQ)

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When Should You See a Doctor?

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Consult a cardiologist without delay in the following situations:

• New or worsening shortness of breath
• Increased swelling in legs, ankles, or abdomen
• Unusual fatigue and weakness
• Palpitations or irregular heartbeat
• Chest pain or pressure
• Fainting or feeling faint
• Waking up at night with shortness of breath

If you have been diagnosed with mitral or tricuspid valve disease, regular cardiology follow-up is important. Early evaluation and timely intervention provide the best results.

Appointment and Contact

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If you would like to schedule an appointment for MitraClip or tricuspid valve intervention evaluation:

📍 Avrasya Hospital - Beştelsiz Mah. 101. Sokak No:107, Zeytinburnu, Istanbul

📞 Phone: +90 212 665 50 50 (Ext: 4012)