The MitraClip and Heart Failure

 

Alright, so this blog post is a bit long, but I loved this couple, and his story is pretty typical for people dealing with chronic heart failure, so I wanted to do it justice… so sorry, not sorry!

The physician I worked with often provided cardiology care for couples, scheduling their appointments togethers. One such couple had been following for over 20 years and were some of my favorite patients. The husband had 4 chamber dilated cardiomyopathy. Basically all 4 chambers of his heart were wider than they should be, which only increased the workload on his heart and decreased his overall cardiac efficiency. At this point, his medications were hardly helping and because of the dilation he had severe valvular regurgitation. Meaning the leaflets on the mitral and tricuspid valves could not close all the way when the ventricles contracted as the leaflets could not reach each other, allowing a significant amount of blood that was supposed to be being pumped to the rest of his body and his lungs, to flow back into the atria. As you can imagine (BL 618 people I’m looking at you) this reduced his cardiac output, leading to significant shortness of breath, peripheral edema, ascites (fluid collection in the abdomen), and malaise. Basically, he felt like crap. He was not a great candidate for an open-heart valve replacement surgery given his age, comorbidities, and the fact that surgery would not cure his underlying heart failure. We were trying to figure out what we could do to help ease his symptoms and make him more comfortable. He was already coming to the hospital for paracentesis every two weeks to remove the fluid accumulating in his abdomen as his organs struggled to keep up. We were running out of conventional treatment options and our patient was miserable and in poor spirits.

            The physician mentioned a MitraClip (Figure 1 and 2) could be an option for alleviating his symptoms. The MitraClip, is basically a “staple” that is meant to hold the leaflets of valves together in cases of severe mitral valvular regurgitation. The MitraClip implant is a transcatheter procedure, meaning it is done via a catheter through the femoral artery eliminating the need for open-heart surgery (which is a very exciting advancement for valve procedures!) Originally, this device was approved only for use in patients whose mitral regurgitation (MR) was due to structural issues with the valves, such as stenosis (stiffening of the valve leaflets). Recently, however, the FDA approved MitraClips to be used on valves that were “leaky” due to heart failure rather than just a structural issue, due to the significantly improved quality of life seen in patients involved in the clinical trial.

                                                            Figure 1.

                                                         Figure 2.

Now as exciting as this new indication for the use of the MitraClip is, it does not cure the underlying heart failure. After the physician mentioned this, we had an interesting conversation on ethics as we wondered if this procedure would only prolong the inevitable (I know, sounds super morbid but that’s the reality) which brings in the question of non-malfeasance (ethics trigger word!), or if this could be the best option for the patient and would be acting with beneficence to help his symptoms. Regardless of what our opinion was, it was important that our patient maintain his autonomy and make the decision for himself. We therefore decided to present him with this as a treatment option but provide education on what the procedure entailed and inform him that it may work, or it may not and he could undergo a procedure with no resolution in his symptoms. Thus ensued one of the most emotional and honest conversations I have ever been a part of with a patient as we explained his condition was only worsening, he likely did not have much longer to live, and there was no promise this procedure would improve his symptoms or prolong his life…but it was a possibility and he deserved to hear all his options. Ultimately, he wanted the procedure.

We sent our patient to a structural cardiothoracic surgeon who thought he was a good candidate and ultimately ended up placing two MitraClips in his Mitral Valve and one in his Tricuspid Valve! That’s a lot of clips! For reference, normally patients only receive one or two clips and in only one valve.

His symptoms improved! During his next office visit, we immediately noticed his spirits were lifted, his color was better, his breathing had improved, he seemed to have stabilized! This went on for about 6 months, but eventually his symptoms worsened. This procedure had improved his quality of life for a time, but ultimately, they did not cure his underlying heart failure and overall reason his valves had “failed” in the first place. He passed away soon after his symptoms returned. When we met with his wife later (as she was also a patient of this physician), she mentioned he had been happy for the extra time and the brief reprieve in his symptoms. I don’t believe there is a right or wrong medical decision that could have been made in this case, but I do believe patient education and presenting all his options was a very important ethical decision.

https://www.abbott.com/corpnewsroom/products-and-innovation/mitraclip-now-helps-many-more-with-smr.html?CID=PS_BIS_HH_GA_287&gclid=Cj0KCQiAys2MBhDOARIsAFf1D1dXs87ZsgoYRF8EUpeiuN7X9ULsJ_SC271mkjd7HWslGLcT7rkmXaYaAmnBEALw_wcB&gclsrc=aw.ds