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Ann Thorac Surg 2010;89:72-80. doi:10.1016/j.athoracsur.2009.08.063
© 2010 The Society of Thoracic Surgeons
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Michael Argenziano
Eric Skipper
David Heimansohn
George V. Letsou
Irving Kron
John Alexander
Joseph Cleveland
Bobby Kong
Michael Davidson
Thomas Vassiliades
Karl Krieger
Pierre Tibi
Aubrey Galloway
Ted Feldman
Donald Glower
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Right arrow Minimally invasive surgery
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Original Articles: Adult Cardiac

Surgical Revision After Percutaneous Mitral Repair With the MitraClip Device

Michael Argenziano, MD*, Eric Skipper, MD, David Heimansohn, MD, George V. Letsou, MD, Y. Joseph Woo, MD, Irving Kron, MD, John Alexander, MD, Joseph Cleveland, MD, Bobby Kong, MD, Michael Davidson, MD, Thomas Vassiliades, MD, Karl Krieger, MD, Ed Sako, MD, Pierre Tibi, MD, Aubrey Galloway, MD, Elyse Foster, MD, Ted Feldman, MD, Donald Glower, MD, EVEREST Investigators

Columbia University College of Physicians and Surgeons, New York, New York

Accepted for publication August 20, 2009.

* Address correspondence to Dr Argenziano, Columbia University College of Physicians and Surgeons, 177 Fort Washington Ave, Milstein Hospital, Suite 7-435, New York, NY 10032 (Email: ma66{at}columbia.edu).

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 
Background: Percutaneous mitral repair with the MitraClip device (Evalve, Menlo Park, CA) has been reported. Preserving conventional surgical options in the event of percutaneous treatment failure is important. We describe surgical treatment at varying intervals after the MitraClip procedure in 32 patients.

Methods: One hundred seven patients with moderate-to-severe or severe mitral regurgitation who were either symptomatic (91%) or, if asymptomatic (9%), had evidence of left ventricular dysfunction were enrolled as part of the Endovascular Valve Edge-to-Edge REpair STudy (EVEREST) phase I registry study or as "roll-in" subjects in the EVEREST II study. Thirty-two of the 107 patients (30%) underwent surgery after an attempted MitraClip procedure.

Results: Of the 32 patients undergoing post-clip mitral valve surgery, 23 patients (72%) had one or more clips implanted and 9 patients (28%) received no clip implant. The indications for mitral valve surgery in the 23 patients with a clip included partial clip detachment (n = 10), residual or recurrent mitral regurgitation greater than 2+ (n = 9), and other (atrial septal defect [n = 2], device malfunction [n = 1], and incorrectly diagnosed mitral stenosis [n = 1]). Twenty-seven of 31 patients (87%) underwent the surgical procedure planned before surgery (planned procedure unknown in 1 patient). Four of 25 patients (16%) with planned repair underwent mitral valve replacement.

Conclusions: Standard surgical options were preserved in patients who had surgery after percutaneous repair with the MitraClip device. Successful repair was feasible in the majority of patients after the MitraClip procedure, with repair performed as late as 18 months after clip implantation.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Discussion
 References
 
In the last decade, there have been significant advances in percutaneous intracardiac techniques. While current technology allows definitive management of coronary disease, vascular occlusive disease, and many congenital cardiac defects, treatment of valvular pathology has been limited to relatively less refined techniques, such as balloon valvuloplasty. Based on the success of the "edge-to-edge" surgical technique introduced in 1991 by Alfieri [1-4] for the surgical treatment of mitral regurgitation (MR), a percutaneous device has been designed, using a catheter-delivered clip rather than a suture to secure the mitral leaflets [5]. The MitraClip device (Evalve, Menlo Park, CA) is delivered to the mitral valve (MV) through percutaneous femoral venous transseptal access.

Percutaneous mitral repair using the MitraClip device has been previously described, and has been evaluated in prospective multicenter studies [6-8]. Enrollment in the Endovascular Valve Edge-to-Edge REpair STudy (EVEREST) I registry and the EVEREST II high-risk registry and randomized arms is complete. The purpose of this report is to describe patients who underwent MV surgery when percutaneous repair with the MitraClip device was not successful.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Discussion
 References
 
Study Design
The EVEREST study is a prospective multicenter study. The EVEREST I and II studies have been approved by the Food and Drug Administration, Institutional Review Boards, Health Canada, and local Canadian Ethics Boards. All patients signed informed written consent. The study requires evaluation of all echocardiographic studies by a core laboratory. The trial is registered with the FDA at www.clinicaltrials.gov.

Study population
The patients described in this report are from a study population that includes 55 patients treated in the EVEREST phase I feasibility trial, and 52 roll-in patients treated in the EVEREST II pivotal trial (these represent the prerandomization initial experience for the phase II trial sites). Thirty-one North American sites contributed to this population of 107 patients.

Percutaneous mitral repair system
The MitraClip system has been described previously [5-7]. The MitraClip device is approximately 4 mm wide and 8 mm long. Anterior and posterior leaflet tissue is independently secured between two components of the clip, simulating the Alfieri suture repair.

Patient selection
Patients were selected for the MitraClip device if they met basic criteria for intervention from the 1998/2006 American College of Cardiology (ACC)/American Heart Association (AHA) joint task force recommendations regarding therapy for valvular heart disease. Patients with at least moderate-to-severe functional or structural MR who were symptomatic, or if asymptomatic, with compromised left ventricular function (left ventricular ejection fraction less than 60% or left ventricular end-systolic dimension greater than 45 mm [40 mm after release of the 2006 Guidelines]) were candidates (Table 1). To be eligible for enrollment, patients also had to be eligible for either repair or replacement MV surgery as determined by a cardiac surgeon.


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  		Table 1 Etiology for the Enrolled Population and for Patients Who Underwent Post-Clip Mitral Valve Surgery
 
Determination of surgical strategy before the MitraClip procedure
Pre-MitraClip surgical strategy in the EVEREST I feasibility study was not required to be prospectively collected. Therefore, a retrospective review of screening echocardiographic studies, operative notes, preclip patient demographics, and comorbidities was performed to help assess surgical strategy for EVEREST I patients undergoing surgery after clip attempt. The EVEREST II protocol was revised to prospectively document surgical strategy before clip attempt.

Surgical intervention
Patients were recommended for surgery post-clip procedure in the following situations: (1) the MitraClip device was not deployed due to the inability to reduce MR effectively with one or two clips; (2) one or two MitraClip devices were deployed without achieving acute procedural success (defined as reduction of MR severity to moderate (2+) or less on the discharge TTE as assessed by the core echocardiography laboratory); (3) initial acute procedural success was achieved, followed by recurrent MR greater than moderate (2+); or (4) development of another indication for surgery (e.g. persistent ASD from transseptal puncture). All operations were performed by surgeons with varying levels of experience in MV repair techniques, and all but one were investigators at EVEREST trial institutions.

Recommended techniques for surgical removal of the MitraClip device
Before MV surgery and clip explant, attempts were made to inform the cardiothoracic surgeon on the recommended techniques for unlocking and removing the MitraClip device from the mitral valve leaflets. These techniques enable the surgeon to unlock and open the arms of the clip using a Frazier suction tube and braided suture, so the MV leaflet tissue can be accessed and withdrawn from the clip.

Mitral Regurgitation Reduction Goals
MitraClip procedural MR reduction goal
The procedural objective was to reduce MR to mild (1+) or less with optimal placement of one or two MitraClip devices.

Protocol MR reduction goal
The protocol MR reduction goal was defined as postprocedure core laboratory–assessed MR severity less than or equal to moderate (2+), the threshold for which patients are no longer recommended for MR reduction surgery per the 1998 and 2006 ACC/AHA guidelines regarding therapy for valvular heart disease.

Surgical MR reduction goal
The goal of surgery was to reduce MR severity to less than or equal to mild (1+), preferably with zero (0+) residual MR. To conclude that the MitraClip device preserves surgical options, the degree of residual MR in patients undergoing post-clip MV repair should mimic the degree of residual MR in patients undergoing repair when no MitraClip procedure is performed.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Discussion
 References
 
A total of 107 patients from 31 sites were enrolled in the EVEREST I study or roll-in phase of the randomized EVEREST II trial. The MR etiology of the patients enrolled is displayed in Table 1. One clip was placed in 65 patients (61%), 2 clips in 31 patients (29%), and no clips (owing to inability to reduce MR satisfactorily [n = 8] or cross the septum [n = 3]) in 11 patients (10%). Clinical features are shown in Table 2. There were no cases of clip embolization; partial clip detachment (defined as detachment of a single leaflet from the clip) occurred in 10 patients (9%), 3 during clip placement, 1 before hospital discharge, 5 between discharge and 30 days, and 1 diagnosed at 12 months. None was associated with clinical events or the need for urgent intervention. In all but 1 patient with recurrent symptoms, partial clip detachments were detected on protocol-driven echocardiograms.


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  		Table 2 Clinical features for the Enrolled Population and Patients Who Underwent Post-Clip Mitral Valve Surgery
 
Seventy percent of patients (75 of 107) remained surgery free after a median follow-up of 386 days. Thirty-two patients treated at 19 sites underwent MV surgery after clip attempt, including 19 of 55 EVEREST I patients and 13 of 52 EVEREST II roll-in patients. Two patients underwent a reintervention to place a second clip before MV surgery. Etiology of MR for the patients who underwent post-clip MV surgery is shown in Table 1. Median age at the time of enrollment for the 32 patients undergoing post-clip MV surgery was 66 years (range, 40 to 86), and 50% were older than age 65. Clinical features for patients who underwent post-clip MV surgery are shown in Table 2. In-hospital outcomes resulting from the clip procedure for the enrolled population are shown in Table 3.


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  		Table 3 In-Hospital Outcomes After Clip Procedure for the Enrolled Population
 
Of the 32 patients who underwent surgery, 9 patients had not received a clip implant owing to the inability to effectively reduce MR. The remaining 23 patients had a clip implant and underwent MV surgery for a number of indications, including partial clip detachment (n = 10), residual or recurrent MR greater than 2+ after clip (n = 9), or other reasons (atrial septal defect [n = 2], device malfunction, ie, inability to unlock and reposition the clip after initial placement [n = 1], and incorrectly diagnosed mitral stenosis [n = 1]; Table 4). The interval between percutaneous and surgical intervention ranged from 0 to 60 days (mean 14, median 2) in the no-clip patients and from 0 to 1,160 days (mean 234, median 58) in the clip patients. Two nonelective operations were performed on the day of the planned clip procedure for complications associated with the transseptal puncture.


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  		Table 4 Indications for Mitral Valve Surgery After Percutaneous MitraClip Procedure
 
At the time of surgery, 11 patients had some degree of leaflet/chordal damage either as a result of the clip procedure (n = 8) or clip removal from the valve (n = 3). Eight of these 11 patients underwent successful MV repair surgery as planned. The remaining 3 patients underwent MV replacement surgery. In 2 of these patients, repair was planned, and in the remaining patient, the presurgical strategy was unknown.

Overall, the surgical procedure planned before surgery is known for 31 of 32 patients. Twenty-seven of 31 patients (87%) underwent the surgical procedure as planned before surgery: MV repair in 21 patients (Table 5), and replacement in 6 patients (Fig 1). Details of the 32 patients who underwent MV repair or replacement surgery are provided in Tables 5 and 6,Go respectively. The surgical strategy was based on preoperative patient characteristics, including echocardiographic valve leaflet abnormalities and comorbidities. In some cases, age was also a consideration in the decision to perform MV repair or replacement surgery. In 4 patients (13%), replacement was performed despite initially planned repair. Three of these 4 patients were intraoperatively converted from repair to replacement. One patient with P2 flail and anterior chordal rupture underwent a chordal transfer to A2 with a sliding plasty P2 and ring annuloplasty, but testing revealed significant residual MR, so replacement was performed. A second patient with P2 flail and anterior chordal rupture (and suspected endocarditis with a positive gram stain) underwent a triangular resection of A2 and quadrangular resection of P2, but required mitral valve replacement because the leaflets did not coapt well. The third patient, with functional MR, underwent replacement after the initial repair attempt was abandoned early on. At the time of surgery, this patient was in cardiogenic shock due to an iatrogenic transseptal puncture of the aorta resulting in severe cardiac tamponade. In the remaining patient, an initially successful repair required reoperation and replacement 19 days later. The initial complex repair included a sliding plasty of P2 with a Duran annuloplasty ring, repair of a P3 leaflet tear, and an Alfieri stitch at the posteromedial commissure. In this case, the surgeon postulated that the failed repair might have been attributable to the attempted clip procedure, which weakened the P3 scallop that eventually tore from its suture reattachment at the annulus. Finally, in the patient who underwent MV replacement without a known presurgical strategy, the surgeon cited damage to the leaflets, but did not comment if this damage was the reason for replacement surgery.


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  		Table 5 Details of 21 Patients Undergoing Mitral Valve Repair Surgery After Percutaneous Mitral Repair
 

Figure 1
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  		Fig 1. Surgical patient flow chart. (MV = mitral valve.)

 

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  		Table 6 Details of 11 Patients Undergoing Mitral Valve Replacement Surgery After Percutaneous Mitral Repair
 
Overall, 32 patients had MV surgery performed by 24 different surgeons at 19 institutions. Twenty-one patients (67%) had repair and 11 patients (33%) had replacement surgery. Of the 11 replacements, at least 6 were planned preoperatively (1 patient's surgical strategy was unknown) because of complex valve pathology (which in the judgment of the individual surgeon was unlikely to result in successful repair), comorbidities, or advanced age. Seventy-eight percent of replacement valves were bioprosthetic, and in 90% of cases, chordal-sparing techniques were utilized. Of the 25 patients in whom a repair was planned preoperatively, 21 (84%) had successful repairs. When combined with the 6 patients having planned valve replacements, a total of 27 of 31 patients with a known presurgical strategy requiring post-clip surgery (87%) had the surgical procedure that had been planned. Of the 13 EVEREST II roll-in patients whose surgical strategy was prospectively captured before the clip procedure, 11 patients (85%) underwent the MV surgery as planned before the clip procedure (9 repairs and 2 replacements). The remaining 2 roll-in patients underwent unplanned replacement surgery.

Successful surgical repair was performed a mean of 145 days (range, 0 to 562) after MitraClip device placement. Four successful repairs were performed more than 1 year after clip placement, with the longest interval being 18 months. In these patients, a fibrous tissue bridge had developed over the clip and the points of leaflet attachment (Fig 2); however, that did not preclude disengagement of the device during explant and successful leaflet-based repair. Durability of post-clip MV repair surgery is presented in Table 7. Nineteen of 21 patients who underwent post-clip MV repair had their MR assessed after surgery. Seventeen of these 19 patients (89%) had their MR assessed after surgery as mild (1+) or less MR, with the 2 remaining patients (11%) assessed with as mild-to-moderate (1 to 2+) MR.


Figure 2
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  		Fig 2. Two in-situ MitraClips 10 months after implantation.

 

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  		Table 7 Mitral Regurgitation (MR) After Mitral Valve (MV) Repair Surgery: Durability of Post-Clip MV Repair Surgery
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Discussion
 References
 
As has been the case for coronary artery disease, the development of a percutaneous treatment for MR is likely to have a major clinical impact, representing a less invasive alternative to conventional (and even minimally invasive) surgical approaches. However, given the proven efficacy, safety, and durability of current surgical mitral repair techniques at centers of excellence, the introduction of a newer, untested percutaneous approach raises questions. For percutaneous techniques to become a reasonable alternative, they must have a risk-benefit profile that matches the safety and efficacy profile of currently available surgical approaches. This is especially true for young, healthy patients, for whom the risks of surgery are minimal and the importance of repair success and durability is paramount.

With regard to the question of safety, preliminary experience with the MitraClip device has shown low procedural morbidity and no procedure-related mortality (a single nonprocedural-related mortality occurred in an 81-year-old patient with a Society of Thoracic Surgeons predicted procedural mortality risk of 18.3% 12 days after an attempted procedure in which MR could not be reduced [6]. The efficacy of the procedure (percentage of patients treated definitively by the MitraClip device), although lower than that observed with standard surgical approaches, is reasonable in the initial experience with this first-in-class device, and will likely improve with increased operator experience, technologic refinements, and maturation of patient selection criteria [9].

One argument advanced by proponents of percutaneous mitral repair with the MitraClip system is that the procedure appears to be safe and achieves efficacy in a significant proportion of patients and should be offered as a first-line treatment for selected patients, with surgical treatment reserved for percutaneous treatment failures. Much as is the case with percutaneous coronary interventions, it is argued, this approach will allow a significant number of patients to delay or altogether avoid the morbidity and potential mortality of surgery. For this argument to be accepted, however, it must also be proved that a failed percutaneous procedure does not somehow "burn bridges," increasing the risk or decreasing the success rate of subsequent mitral repair surgery.

In the 32 patients who underwent mitral valve surgery after attempted or completed MitraClip procedure, the vast majority (87%) received the operation that had been planned by the 24 different surgeons before surgery, consistent with current surgical experience [10]. Seven of the 11 mitral valve replacements occurred in patients with either complex mitral pathology or comorbidities and other characteristics such as advanced age that made replacement the right choice.

In 4 patients, replacement resulted despite a planned repair. In 3 of these patients, the need to replace the mitral valve did not appear to be related to the MitraClip procedure. The remaining unplanned replacement after clip implant was potentially caused by damage to the one of the leaflets during the attempted clip procedure, but other contributory factors could not be ruled out. Because of the additional concern that patients with clips in place might not be amenable to repair beyond the acute term, it is relevant to note that 4 repairs were performed more than 1 year after MitraClip deployment. When including the 75 clip repair patients, 90% of the overall patient cohort (96 of 107) had either a percutaneous or surgical valve repair. The patient whose planned procedure was unknown had minor damage to the leaflets and underwent MV replacement. It is unknown whether a repair was feasible. This EVEREST I patient underwent the MitraClip procedure before modifications in the grasping technique and before implementation of anatomic screening using TEE.

In summary, our surgical experience with the initial cohort of patients undergoing repair with the MitraClip device indicates that at least in the short term, surgical options are preserved in most patients after attempted or successful deployment of a MitraClip device. The long-term durability of these repairs, and the surgical repairability of late failures, cannot yet be assessed with the current data. A clearer assessment of efficacy and durability will be provided by the randomized arm of EVEREST II, in which repair with the MitraClip device is compared directly with surgical approaches.


   Discussion
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
References
 
DR THORSTEN WAHLERS (Cologne, Germany): I have a question concerning the 21 repairs that were subsequently done. Can you give us additional information on how good the surgical repair was concerning the grade of MI or no MI achieved?

DR ARGENZIANO: I was asked to limit this to 20 slides, but we did have a few slides on this. Of the 21 patients who had surgical repairs, 16 had at least 3-month echocardiographic follow-up, and 3 had greater than 1-year echocardiographic follow-up. In none of these patients, and at no time point, was there more than 1+ MR.

DR SAQIB MASROOR (Hackensack, NJ): The 7 patients who were preoperatively determined to have a replacement—I don't understand, how did they end up getting a clip repair if they needed a replacement?

DR ARGENZIANO: Just to clarify that, there are several reasons why a surgeon might lean toward a replacement in a patient. One of them might be age, one of them might be comorbidity, et cetera. But frankly, there were several patients in this trial—for instance, an 80-year-old patient with severe myxomatous disease, bileaflet pathology, a torn P2 and a stretched-out A2—that you might say, "I don't think I am going to repair that valve." But for the E-valve procedure, there is really no option; you can't replace the valve. So those patients might be perfectly reasonable candidates for an attempted percutaneous repair. But once you have gotten to the point of opening their heart and cross-clamping, et cetera, you make a decision as to what is best for the specific patient.

DR FRIEDRICH W. MOHR (Leipzig, Germany): Although I will talk about this subject later on, I just need to get up to comment on these results. I think we are in a very dangerous situation here, if we as surgeons accept the definition of success given by cardiologists like you did on your slides; if you are going to call 2+ MR as a surgeon a success, I think might be there is something wrong. If you perform mitral repair like that in open surgery, you will get a call from your cardiologist the very next day?

If you look at good surgical data, a success rate means that 80% to 90% of all the repairs have no regurgitation at all and maybe 10% have 1+ regurgitation and this is it. Looking at all the patients I have seen from Ted Feldman, I think we as surgeons have to state that all these patients would have a surgical 100% repair, in good hands, no valve replacement.

I think we also say that the Alfieri procedure by itself is not the most successful repair technique in most of the valves. As such, we adapt a questionable surgical technique for such cases for the interest of a catheter-based intervention. So how can you expect perfect results? Since we know the good long-term results results of surgical repair and failure rate is only 1% to 1.5% per year, we should not just now allow talk about success rates, which is not really a success.

DR ARGENZIANO: Yes, Fred, I agree with you 100%. Believe it or not, at the investigator meeting, I said all the same things, and I have always said those things. Let's be clear on the purpose of this presentation. The question here is, these percutaneous procedures are being done, and the question from a surgical perspective that we were trying to ask is, what happens to the patients that we wind up operating on? In other words, is the premise correct that these patients' eventual outcomes are not adversely impacted by a percutaneous repair attempt? Given that percutaneous technology is being developed and the procedures are being done, the question is, what do we as surgeons do about it and how do we adapt?

I also have all sorts of concerns about the definition of success being an MR grade of 2+ or less. When I have given the larger version of this presentation, the question is always, what happens to those patients 5 years from now, 10 years from now if their residual MR is 2+? That is not the question here. The question here specifically was, what happens to the patients who have failed percutaneous procedures? Because if we find that 50% of the patients have their valves torn apart by this technology so that they are subsequently unrepairable, then we have an acute problem, right? But that acute problem was not encountered in our series. In other words, the vast majority of the patients who were operated on by a very talented group of surgeons that we had working with us were able to get the repair that they should have gotten. That is all we are saying here. We are not validating or criticizing the underpinnings of the percutaneous technology. So although I agree with your sentiments, I believe we need to continuously strive to improve our art as surgeons, and in this case, that means learning how to deal with failed percutaneous repairs.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Discussion
 References
 

  1. Alfieri O, Maisano F, De Bonis M, et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems J Thorac Cardiovasc Surg 2001;122:674-681.[Abstract/Free Full Text]
  2. Kinnaird TD, Munt BI, Ignaszewski AP, Abel JG, Thompson RC. Edge-to-edge repair for functional mitral regurgitation: an echocardiographic study of the hemodynamic consequences J Heart Valve Dis 2003;12:280-286.[Medline]
  3. Bhudia SK, McCarthy PM, Smedira NG, Lam BK, Rajeswaran J, Blackstone EH. Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings Ann Thorac Surg 2004;77:1598-1606.[Abstract/Free Full Text]
  4. Maisano F, Caldarola A, Blasio A, De Bonis M, La Canna G, Alfieri O. Midterm results of edge-to-edge mitral valve repair without annuloplasty J Thorac Cardiovasc Surg 2003;126:1987.[Abstract/Free Full Text]
  5. Feldman T, Leon MB. Prospects for percutaneous valve therapies Circulation 2007;116:2866-2877.[Free Full Text]
  6. Feldman T, Wasserman HS, Herrmann HC, et al. Percutaneous mitral valve repair using the edge-to-edge technique: six-month results of the EVEREST phase 1 clinical trial J Am Coll Cardiol 2005;46:2134-2140.[Abstract/Free Full Text]
  7. Silvestry FE, Rodriguez LL, Herrmann HC, et al. Echocardiographic guidance and assessment of percutaneous repair for mitral regurgitation with the Evalve MitraClip: lessons learned from EVEREST I J Am Soc Echocardiol 2007;20:1131-1140.
  8. Foster E, Wasserman HS, Gray W, et al. Quantitative assessment of severity of mitral regurgitation by serial echocardiography in a multi-center clinical trial of percutaneous mitral valve repair Am J Cardiol 2007;100:1577-1583.[Medline]
  9. Hermiller J, Kar S, Rinaldi M, et al. Percutaneous mitral repair with the MitraClip device for functional mitral regurgitation: acute success and 12-month durability Am J Cardiol 2007;100(Suppl):216L.
  10. Hellemans I, Pieper E, Ravelli A, et al. Prediction of surgical strategy in mitral valve regurgitation based on echocardiography Am J Cardiol 1997;79:334-338.[Medline]



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