What is mitral valve insufficiency?
There are four valves in the heart. These valves act like doors that open in one direction. That is, they allow blood to pass in only one direction. The mitral valve, which is one of them, connects the two chambers on the left side of the heart (the left atrium and the left ventricle) and consists of two parts: the anterior and posterior leaflets. If these two leaflets do not close completely, a gap remains between them and blood leaks back through it. This is called mitral valve insufficiency (mitral valve regurgitation or mitral valve leakage). The larger the gap, the greater the leakage. Accordingly, the leakage is classified as “mild,” “moderate,” or “severe.” Mild and mild-to-moderate leakages do not cause any complaints and do not require treatment. In some cases, mild or moderate leakages may progress over time, meaning they can get worse, but in most cases, they do not progress. Remaining under a doctor’s follow-up at regular intervals with ECHO (heart ultrasound) is sufficient. However, if during follow-ups more than half of the blood is leaking back, it means the problem has reached a ‘severe (serious) degree.’ In severe mitral valve insufficiency, the amount of blood sent to the body is also significantly reduced. The heart, therefore, has to work harder. This causes fatigue, shortness of breath, getting tired easily, palpitations, swelling in the legs, and eventually heart failure. Quality of life deteriorates, and even performing ordinary daily activities becomes difficult. It should also be emphasized that (primary) severe mitral valve insufficiency can cause heart failure, and heart failure developed due to another reason can subsequently cause (secondary) mitral valve insufficiency.
What is MitraClip?
MitraClip is one of the treatment methods applied to correct mitral valve insufficiency, whether it is primary or secondary. It is a type of clip (Turkish; Mandal). The clip, attached to the anterior and posterior leaflets in the area where the leakage occurs on the valve, prevents or significantly reduces the leakage. This repair method, also known as clipping, is applied if the leakage in the mitral valve is moderate-to-severe (3+) or severe (4+) [Mild (1+) or mild-to-moderate (2+) leakages do not require a clip or surgery].
What is Pascal?
Pascal is an alternative clip brand that began to be used in our country as of 2024 (Edwards Lifesciences). MitraClip is also a brand (Abbott Structural). In other words, both MitraClip and Pascal are types of clips.
What is DragonFly?
DragonFly is another clip brand that began to be used in our country as of 2025 (Valgen Medtech).
Which is better: MitraClip, Pascal, or DragonFly?
According to the results of comparative scientific studies, there is no significant difference between MitraClip and Pascal in terms of quality and benefit provided to the patient (See References). The structure of DragonFly is very similar to that of MitraClip and Pascal. However, scientific studies comparing DragonFly with MitraClip or Pascal are not yet available.
Even if heart surgery isn’t very risky, could the clamp method be preferred?
The clipping method is applied only to patients who are at such high risk that they cannot undergo surgery. This is because, if the patient is not high-risk, scientific studies have shown that surgery is better than clipping; in other words, the patient’s symptoms improve more with surgery, the probability of recurring leakage in the valve is lower in the long term, and the life expectancy is longer. In surgery, repairing the valve is generally better than replacing it. For patients at very high risk for surgery, scientific guidelines recommend that the clipping method be preferred over the ‘medication-only’ method when the appropriate patient is selected (See References).
Mandal yöntemi, sadece, ameliyat olamayacak kadar riskli olan hastalara uygulanır. Çünkü, hasta yüksek riskli değilse ameliyatın mandaldan daha iyi olduğu bilimsel çalışmalarda gösterilmiştir; yani ameliyat ile hastanın şikayetleri daha çok düzelir, uzun vadede kapakta yeniden kaçak gelişme olasılığı daha azdır ve yaşam süresi daha uzundur. Ameliyatta ise mümkünse kapağın tamir edilmesi, kapağın değiştirilmesinden genellikle daha iyidir. Ameliyat için çok riskli hastalarda ise bilimsel kılavuzlar uygun hasta seçildiğinde mandal yöntemini ‘sadece ilaçla tedavi’ yöntemine tercih edilmesini önermektedirler (Bkz. Referanslar).
Is clothespin therapy an experimental treatment method?
No. It is an effective treatment method that has been applied to more than 150,000 patients worldwide to date (See References).
What examinations are performed before the clamping process?
- Blood test: For checking conditions such as anemia, kidney failure, and infection.
- ECG: To determine whether there is a rhythm disorder in the heart.
- Surface ECHO (TTE) and endoscopic ECHO (TEE): To determine whether the mitral valve anatomy is suitable for a clip and to assess the pumping power of the heart.
What are the risks of the latch operation?
As with any interventional procedure, there are some risks involved in the clipping procedure. Serious complications (stroke, heart attack, and death) occur in 5 out of every 100 people. You may be right to be worried about these risks; but remember: these complications occur rarely. What is important is whether the clipping procedure is truly necessary. If the decision has been made in accordance with current scientific data and guidelines, it means “the benefit of the procedure outweighs the risk of the procedure.” In this case, not performing the procedure means being more exposed to serious risks, including death.
Prof. Dr. Şükrü Akyüz is an interventional cardiologist. His field of expertise is the non-surgical treatment of heart diseases, including the clipping method.
How is the latch operation performed?
The clipping procedure is performed in a catheterization laboratory (angio room) or in hybrid rooms. The patient’s heart continues to function throughout the procedure; therefore, there is no need to be connected to a heart-lung machine. The chest cavity is not opened either. For this reason, it is a non-surgical method. In this method, the clip, which is located inside a long and flexible tube (catheter), is sent to the heart through the groin vein. This catheter is controlled from the outside via a special mechanical control system. Sometimes one clip is not enough; it may be necessary to attach a second or even a third clip.
Is there any pain during the clamping process?
No. The procedure is performed either under sedation or under general anesthesia. The difference is this: In general anesthesia, a tube is inserted into the patient’s airway and a ventilator provides the air; in sedation, no respiratory tube is inserted, the patient is not connected to a ventilator, the patient is simply put to sleep, and they breathe on their own. In both techniques, medications are given to prevent the patient from feeling pain throughout the procedure. Since the TEE cable (probe) will remain in the esophagus during the procedure and the patient would find this uncomfortable, performing the procedure under general anesthesia is more comfortable for the patient and is generally the preferred method.
How long does the latch process take?
The average time is 1.5 hours. Each patient’s characteristics are different, and therefore, this time may be shorter or longer.
When can I be discharged after the clamping procedure?
After the procedure, the patient is usually discharged the next day. Each patient’s characteristics are different, and therefore, this period may be shorter or longer.
Can the clothespin be felt on the body?
No, it’s imperceptible. It doesn’t make any sound that can be heard from the outside either.
Will the latch come loose later?
It is quite rare for the latch to come loose later in life. If it does, it almost always happens within the first month.
What is TriClip?
While the clip attached to the mitral valve of the heart (on the left) is called MitraClip, the clip attached to the tricuspid valve (on the right) is called TriClip. TriClip is a brand name belonging to Abbott Structural. Clipping can also be performed on the tricuspid valve with Pascal. The placement of a clip on the tricuspid valve is a relatively newer application. It may be preferred for patients who have severe tricuspid valve leakage, do not respond to medications, and cannot undergo surgery. Since there is not yet as much scientific data as there is for the mitral valve, more scientific evidence is needed for its more widespread use.
What is TEER?
TEER is the abbreviation for the English expression “transcatheter edge-to-edge repair.” It means “repair from edge to edge with a catheter” and is the medical name for the clipping method. Therefore, in the medical community, it is preferred to use the term TEER, which is a general medical name, instead of using the specific brand names like MitraClip, TriClip, DragonFly, and Pascal.
Instead of using a clamp, could the mitral valve be replaced using a non-surgical method?
Scientific studies on the non-surgical replacement of the mitral valve are still ongoing. Some of these studies are seeking an answer to the question: “Is it better to replace the valve non-surgically, or to attach a clip to the valve?” Our estimation is that within 10 years, the mitral valve will be able to be replaced using catheters sent to the heart via the groin vein in a non-surgical method, just as in TAVI. The first scientific data on this subject are promising.
Who is the clamp method NOT suitable for?
The goal of MitraClip or Pascal is to reduce severe (4+) or moderate-to-severe (3+) regurgitation to a mild (1+) or mild-to-moderate (2+) level, provided it does not cause significant narrowing of the valve (completely eliminating the leakage is quite difficult). According to current real-life data, if the clipping procedure is performed on a patient who is clinically and anatomically suitable, 3 out of every 4 patients state that their complaints have decreased; meaning they feel less tired, breathe better, and their quality of life has improved (See References). However, unfortunately, in 1 out of every 4 patients, the desired level of improvement cannot be achieved despite everything. In some of these patients, partial improvement is achieved, while in others, there is no improvement at all. Our own clinical experience is consistent with this data. The clipping procedure should not be performed on a patient who is not suitable clinically or anatomically. This is because it is known that the clip provides no benefit in this group of patients (See References). The most important patient groups that are not suitable clinically or anatomically for clipping are as follows:
- Patients with mild (1+) or mild-to-moderate (2+) mitral valve regurgitation (Because it is sufficient for these patients to remain under medical follow-up.)
- Patients who have not been started on appropriate medical therapy or whose therapy is incomplete (Because well-regulated medication can reduce the leakage in the valve, potentially making the clip unnecessary.)
- Patients who require a heart failure-specific pacemaker (CRT) (Because a CRT device can reduce valve leakage in patients with left bundle branch block on their ECG, potentially making the clip unnecessary.)
- Patients with very low cardiac pumping power (Meaning those with an EF value of less than 20%; because end-stage heart failure generally does not respond to clip therapy. However, in this patient group, if no other treatment options remain, including heart assist devices and heart transplantation, the clipping method may still be tried, keeping in mind that the probability of effectiveness is low.)
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References
- Otto CM, Nishimura RA, Bonow RO, et al. ACC/AHA Guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2021 Feb 2;77(4):e25-e197.
- Vahanian A, Beyersdorf F, Praz F, et al. ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561-632.
- Sorajja, Sato H, Bapat VN, et al. Contemporary anatomic criteria and clinical outcomes with transcatheter mitral repair. Circ Cardiovasc Interv. 2023;16:e012486.
- Obadia JF, Messika-Zeitoun D, Leurent G, et al; MITRA-FR Investigators. Percutaneous repair or medical treatment for secondary mitral regurgitation. N Engl J Med. 2018 Dec 13;379(24):2297-2306.
- Stone GW, Lindenfeld J, Abraham WT, et al; COAPT Investigators. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018 Dec 13;379(24):2307-2318.
- Lim DS, Herrmann HC, Grayburn P, et al. Consensus document on non-suitability for transcatheter mitral valve repair by edge-to-edge therapy. Structural Heart. 2021;5:227-233.
- Zahr F, Smith RL, Gillam LD, et al; CLASP IID Pivotal trial investigators. One-year outcomes from the CLASP IID randomized trial for degenerative mitral regurgitation. JACC Cardiovasc Interv. 2023;16(23):2803-2816.