Title : Comparative outcomes of mitraclip therapy versus surgical and conservative management for mitral regurgitation: A meta-analysis
Abstract:
Background: Mitral regurgitation (MR) is a prevalent valvular heart disease associated with significant morbidity and mortality. While surgical mitral valve repair or replacement remains the gold standard, transcatheter mitral valve repair (TMVR) using the MitraClip has emerged as a viable option for high-risk surgical candidates. The MitraClip provides a minimally invasive alternative that is particularly beneficial for patients who are considered unsuitable for surgery due to comorbidities. This meta-analysis compares the clinical outcomes of MitraClip therapy versus surgical and conservative management in patients with MR, emphasizing its efficacy, safety, and long-term durability.
Methods: A systematic review and meta-analysis were conducted using data from six key studies: Benito-Gonzalez et al. (2017), Wang et al. (2020), Wan et al. (2013), Giannini et al. (2018), Oh et al. (2020), and Yuan et al. (2021). Studies comparing MitraClip, surgical repair/replacement, and medical therapy were included. Primary outcomes assessed included all-cause mortality (short- and long-term), heart failure (HF) hospitalizations, recurrent MR, and need for reoperation. Secondary outcomes included procedural success, 30-day mortality, length of hospital stay, stroke incidence, and pacemaker implantation. A random-effects model was used to pool outcome estimates, ensuring statistical robustness and accounting for variability across studies.
Results:
- All-cause mortality: MitraClip showed comparable short-term (≤30-day) mortality rates to surgery (2.06% vs. 2.06%) but demonstrated improved one-year survival compared to medical therapy (15.14% vs. 29.04%).
- Heart failure hospitalizations: MitraClip combined with medical therapy significantly reduced HF hospitalizations compared to medical therapy alone (OR 0.57, 95% CI: 0.36–0.91, p=0.02). This suggests a potential protective role for MitraClip in preventing HF-related complications.
- Recurrent mitral regurgitation: Higher rates of residual MR (≥ moderate) were observed in the MitraClip group compared to surgery (17.2% vs. 0.4%, p<0.0001), indicating that surgery remains more effective in achieving sustained MR reduction.
- Reoperation rate: MitraClip was associated with an increased need for reoperation compared to surgery (OR 5.28, 95% CI: 3.43–8.11, p<0.01), highlighting the importance of patient selection criteria to minimize repeat interventions.
- Length of stay: MitraClip patients had significantly shorter hospital stays compared to surgical patients (-3.86 days, p<0.01), though long-term durability remains a concern due to the higher likelihood of recurrent MR.
- Stroke and pacemaker implantation: No significant differences were observed between groups, indicating that MitraClip is as safe as surgical intervention in terms of thromboembolic complications and conduction disturbances.
Discussion: MitraClip therapy provides a valuable alternative for high-risk surgical candidates, demonstrating similar short-term mortality and reduced HF hospitalizations compared to surgery and medical therapy. However, the increased risk of recurrent MR and need for reoperation highlight the limitations of MitraClip in achieving long-term durability. Surgery remains the superior option for patients who are surgical candidates due to its better MR resolution and lower reoperation rates. The clinical decision-making process should consider patient-specific factors, including anatomical suitability, baseline comorbidities, and long-term quality of life expectations. This analysis underscores the need for standardized guidelines to optimize the selection of candidates who will benefit most from MitraClip therapy.
Conclusion: This meta-analysis supports MitraClip as an effective intervention for high-risk patients with MR, offering survival benefits over medical therapy. However, in lower-risk populations, surgical repair remains the preferred strategy due to superior long-term MR reduction and durability. Further randomized controlled trials with long-term follow-up are needed to refine patient selection and optimize treatment strategies. Additionally, future research should focus on improving MitraClip technology to enhance its durability and minimize recurrent MR, thus broadening its applicability across a wider patient spectrum.
