MitraClip Procedure Mitral Valve Repair Without Surgery

MitraClip is a transcatheter edge-to-edge repair (TEER) technique that places a small clip on the mitral valve leaflets via a catheter through the femoral vein — without opening the chest. The clip grasps and approximates the anterior and posterior leaflets, reducing the degree of backwards blood leakage through the valve. The procedure is performed under general anaesthesia with real-time transoesophageal echocardiographic (TOE) guidance. Hospital stay is 2–3 days. Most patients experience significant improvement in breathlessness within days.

In carefully selected heart failure patients with severe functional mitral regurgitation, MitraClip reduces the volume of blood leaking backwards through the mitral valve — decreasing the volume burden on the left ventricle and reducing pulmonary congestion. The COAPT trial (NEJM 2018, n=614) demonstrated MitraClip reduced heart failure hospitalisation by 47% and all-cause mortality by 38% at 2 years compared to optimal medical therapy alone. These results directly updated the 2021 ESC Heart Failure Guidelines, which now give MitraClip a Class IIa recommendation for appropriate patients.

Primary (degenerative) mitral regurgitation occurs when the mitral valve itself is structurally abnormal — most commonly due to mitral valve prolapse, chordal rupture, or rheumatic disease. Secondary (functional) mitral regurgitation occurs when the valve is structurally normal but fails to close because the left ventricle is enlarged by heart failure, pulling the valve leaflets apart. The distinction matters for MitraClip: the strongest evidence is in secondary/functional MR in heart failure (COAPT trial). For primary MR in surgically fit patients, open surgical repair is preferred.

For primary (degenerative) MR in a surgically fit patient, open-heart surgical valve repair remains the gold standard — it achieves more complete anatomical correction. The EVEREST II trial showed MitraClip is safer but produces more residual MR compared to surgery. For secondary (functional) MR in heart failure patients at high surgical risk, MitraClip is preferred — the COAPT trial shows clear clinical benefit and surgery in this population carries prohibitive mortality. The Heart Team evaluates each patient individually — there is no universal answer.

After MitraClip, patients spend 12–24 hours in the Cardiac ICU, then are transferred to the ward. Most are discharged on day 2 or 3. No sternotomy means no chest wound — recovery is dramatically faster than surgical repair. Light activity is permitted from day 1; driving is allowed after 1 week. Most patients notice significant improvement in breathlessness within days. Follow-up echocardiogram at 1 month, 3 months, and annually. Heart failure medications (GDMT) must be continued and optimised — MitraClip works alongside medical therapy, not instead of it.

COAPT enrolled patients with 'disproportionate' functional MR — their MR severity (EROA ≥0.20 cm²) was larger than expected for their degree of LV dilation. In these patients, the MR is a significant independent driver of heart failure deterioration, and reducing it with MitraClip produces major benefit. MITRA-FR enrolled patients with 'proportionate' MR — their MR was largely a consequence of advanced LV dilation, not an independent driver. In these patients, fixing the valve does not address the underlying problem. This patient selection distinction is now the most critical determinant of who will benefit from MitraClip.