ORIGINAL ARTICLE _____________________________________________________________ Mitral Valve Replacement After Mitraclip Therapy Antonio Maria Calafiore, M.D.,* Moheeb Al Abdullah, M.D.,y Angela Lorena Iaco, M.D.,* Aijaz Shah, M.D.,y Azmat Ali Sheikh, M.D.,z Ahmed Allam, M.D.,§ Hatim Kheirallah, M.D.,z Mohammed Othman Awadi, M.D.,{ and Michele Di Mauro, M.D.jj *Department of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia; yDepartment of Adult Cardiology, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia; zDepartment of Research, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia; §Ain Shams University, Cairo, Egypt; {Benha University, Benha, Egypt; and jjDepartment of Heart Disease, University of L’Aquila, L’Aquila, Italy ABSTRACT Background: MitraClip therapy (MCT) is becoming more popular to treat mitral regurgitation (MR) in high-risk patients. It is, however, expanding to lower risk patients with the idea that mitral valve (MV) repair can be performed if surgery will be necessary. We report our surgical experience in patients who underwent MCT and subsequently required MV surgery. Methods: From February 2012 to September 2014, three patients out of 34 who underwent MCT (8.8%) needed surgery because of lesions resulting in new MR. Two of them had functional and the third one degenerative MR. Two patients with functional MR underwent emergency surgery for MV lesions adding a new severe MR, the third one, with degenerative MR, had surgery 377 days after MCT. Results: The MV showed a perforation of the anterior leaflet in one case and P2 completely torn in the second case. MitraClip opening was difficult and caused further injury to the leaflets. The third case developed a severe MV stenosis. All three patients underwent MV replacement with a tissue valve. The postoperative course was uneventful and, after a mean of 14 months, all patients are alive and in NYHA class I or II. Conclusions: The risk of urgent or elective surgery after MCT reduces the possibility of conservative surgery, as the possibility of valve reconstruction is less likely following the severe clip implantation-induced tissue damages. doi: 10.1111/jocs.12540 (J Card Surg 2015;30:414–418) MitraClip (Abbott Laboratories, Abbott Park, IL, USA) therapy (MCT) for treatment of mitral regurgitation (MR) has recently been introduced into clinical practice. 1,2 In general, MCT is limited to patients deemed inoperable or at prohibitive surgical risk. 3,4 There is a trend to expand the indications to less risky patients as an alternative to conventional surgical treatment. Studies reported that surgical options were preserved in most patients after successful or attempted deployment of a MitraClip device. 5 We report our experience in patients undergoing surgery after MCT to evaluate risks and benefits of this technology in non-high-risk patients. PATIENT PROFILE From February 2012 to September 2014, three out of 34 patients who underwent MCT (8.8%) needed surgery because of MCT complications The Institutional Review Board approved the research and waived patient consent. Table 1 shows the preoperative and postoperative clinical and echocardiographic data. Patients were all low risk. All of them refused surgery, against the suggestions of the Heart Team. The choice of a tissue valve in the two patients who underwent emergency surgery was due to their personal preference. Case 1 The mitral valve (MV) showed annular dilatation and restricted movements of both leaflets, with no contra- indications to repair. The MitraClip was deployed in the mid-portion of the MV (A2 and P2 segments). However, the clip remained attached only to the posterior leaflet Conflict of interest: The authors acknowledge no conflict of interest in the submission. Address for correspondence: Antonio Maria Calafiore, M.D., Depart- ment of Adult Cardiac Surgery, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia. Fax: þ966-1-4760543; e-mail: am.calafiore@gmail.com 414 © 2015 Wiley Periodicals, Inc.