Efficacy of Mitraclip in functional <i>versus</i> degenerative mitral regurgitation: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Xuhua ¹ , BAI Qiyuan ¹ , WEI Zhili ¹ , LIU Shidong ² , CHEN Hao ¹ , CHEN Yang ¹ ,  SONG Bing ²

1. The First Clinical Medical College of Lanzhou University, Lanzhou, 730000, P. R. China;
2. Department of Cardiovascular Surgery, The First Hospital of Lanzhou University, Lanzhou, 730000, P. R. China;

Corresponding author：

SONG Bing, Email: songbinldyy@163.com

Keywords：

Transcatheter mitral edge-to-edge repair; MitraClip; functional mitral regurgitation; degenerative mitral regurgitation; systematic review/meta-analysis

DOI：

10.7507/1007-4848.202404036

Video：

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Objective To systematically evaluate the differences in efficacy and outcomes between patients with functional mitral regurgitation (SMR) and degenerative mitral regurgitation (DMR) treated with mitral edge-to-edge repair (TEER) using MitraClip. Methods PubMed, EMbase, the Cochrane Library, Web of Science, China Biomedical Literature Database (CBM), CNKI, Wanfang database, and VIP database were searched in computer. Relevant literature from the database from its establishment to January 2024 was covered. Literature screening, data extraction, and risk of bias assessment for the included studies were performed independently by two researchers. Meta-analysis was performed using Stata18.0 software. Results Fourteen papers were finally included, including 6 707 patients, including 4 161 patients in the SMR group and 2 241 patients in the DMR group. Meta-analysis results showed that patients in the SMR group had a higher 1-year all-cause mortality rate [OR=1.53, 95%CI (1.30, 1.81), P<0.01, I²=0%] and 1-year readmission rate for heart failure [OR=1.9, 95%CI (1.60, 2.26), P<0.01, I²=0%] after MitraClip treatment than the DMR group patients. Postoperative mitral transvalvular pressure difference [SMD=-0.47, 95%CI (-0.65, -0.30), P<0.01, I²=51%] was lower in patients in the SMR group than in those in the DMR group, and the incidence of subsequent secondary open-heart surgery [OR=0.41, 95%CI (0.20, 0.83), P=0.01, I²=0%] was lower in patients in the SMR group. Conclusion The results of Meta-analysis showed that after MitraClip treatment, patients in the SMR group showed better efficacy in the short term, but the medium- and long-term efficacy was not as good as that of patients in the DMR group. The specific type of mitral regurgitation should be considered when choosing a MitraClip treatment strategy to more accurately predict efficacy and prognosis.

1.	Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: A population-based study. Lancet, 2006, 368(9540): 1005-1011.
2.	Trichon BH, Felker GM, Shaw LK, et al. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol, 2003, 91(5): 538-543.
3.	Hu P, Liu XB, Liang J, et al. A hospital-based survey of patients with severe valvular heart disease in China. Int J Cardiol, 2017, 231: 244-247.
4.	叶蕴青, 许海燕, 李喆, 等. 中国不同区域老年瓣膜性心脏病构成和病因分析. 中华老年心脑血管病杂志, 2019, 21(7): 676-682.
5.	潘文志, 周达新, 葛均波. 中国二尖瓣反流患者人群数量的估测. 中国胸心血管外科临床杂志, 2021, 28(5): 495-498.
6.	潘翠珍, 潘文志, 周达新. 二尖瓣反流介入治疗的超声心动图评价中国专家共识. 中国介入心脏病学杂志, 2019, 27(1): 6-12.
7.	陈涛, 于波. 经导管二尖瓣缘对缘修复术在二尖瓣反流中的应用进展. 华西医学, 2023, 38(9): 1281-1287.
8.	Head SJ, van Leeuwen WJ, Van Mieghem NM, et al. Surgical or transcatheter mitral valve intervention: complex disease requires complex decisions. EuroIntervention, 2014, 9(10): 1133-1135.
9.	Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J, 2017, 38(36): 2739-2791.
10.	Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 2017, 135(25): e1159-e1195.
11.	Sorajja P, Vemulapalli S, Feldman T, et al. Outcomes with transcatheter mitral valve repair in the United States: An STS/ACC TVt registry report. J Am Coll Cardiol, 2017, 70(19): 2315-2327.
12.	Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e35-e71.
13.	Mauri L, Foster E, Glower DD, et al. 4-year results of a randomized controlled trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol, 2013, 62(4): 317-328.
14.	Baldus S, Schillinger W, Franzen O, et al. MitraClip therapy in daily clinical practice: Initial results from the German transcatheter mitral valve interventions (TRAMI) registry. Eur J Heart Fail, 2012, 14(9): 1050-1055.
15.	Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: Early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe. J Am Coll Cardiol, 2013, 62(12): 1052-1061.
16.	Grasso C, Capodanno D, Scandura S, et al. One- and twelve-month safety and efficacy outcomes of patients undergoing edge-to-edge percutaneous mitral valve repair (from the GRASP Registry). Am J Cardiol, 2013, 111(10): 1482-1487.
17.	Nickenig G, Estevez-Loureiro R, Franzen O, et al. Percutaneous mitral valve edge-to-edge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011-2012 Pilot European Sentinel Registry. J Am Coll Cardiol, 2014, 64(9): 875-884.
18.	Bonow RO, Carabello B, de Leon AC, et al. ACC/AHA guidelines for the management of patients with valvular heart disease. Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). J Heart Valve Dis, 1998, 7(6): 672-707.
19.	Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med, 2018, 379(24): 2307-2318.
20.	Bavry AA, Arnaoutakis GJ. Perspective to 2020 American College of Cardiology/American Heart Association (ACC/AHA) guideline for the management of patients with valvular heart disease. Circulation, 2021, 143(5): 407-409.
21.	Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med, 2011, 364(15): 1395-1406.
22.	Liu XH, Shi JY, Feng XJ, et al. Short-term and 1-year outcomes after MitraClip therapy in functional versus degenerative mitral regurgitation patients: a systematic review and meta-analysis. J Thorac Dis, 2018, 10(7): 4156-4168.
23.	Chiarito M, Pagnesi M, Martino EA, et al. Outcome after percutaneous edge-to-edge mitral repair for functional and degenerative mitral regurgitation: A systematic review and meta-analysis. Heart, 2018, 104(4): 306-312.
24.	Søndergaard L, Steinbrüchel DA, Ihlemann N, et al. Two-year outcomes in patients with severe aortic valve stenosis randomized to transcatheter versus surgical aortic valve replacement: The all-comers nordic aortic valve intervention randomized clinical trial. Circ Cardiovasc Interv, 2016, 9(6): e003665.
25.	Cota GF, de Sousa MR, Fereguetti TO, et al. Efficacy of anti-leishmania therapy in visceral leishmaniasis among HIV infected patients: A systematic review with indirect comparison. PLoS Negl Trop Dis, 2013, 7(5): e2195.
26.	Henández-Vaquero D, Pascual I, Almendarez M, et al. Initial experience of a MitraClip valve repair program in Spain. Ann Transl Med, 2020, 8(15): 957.
27.	Kar S, von Bardeleben RS, Rottbauer W, et al. Contemporary outcomes following transcatheter edge-to-edge repair: 1-year results from the EXPAND study. JACC Cardiovasc Interv, 2023, 16(5): 589-602.
28.	Kheifets M, Angelini F, D'Ascenzo F, et al. Outcomes of transcatheter edge-to-edge repair in degenerative vs. functional mitral regurgitation. J Clin Med, 2022, 11(20): 6010.
29.	Mantegazza V, Pasquini A, Agati L, et al. Comprehensive assessment of mitral valve geometry and cardiac remodeling with 3-dimensional echocardiography after percutaneous mitral valve repair. Am J Cardiol, 2018, 122(7): 1195-1203.
30.	Öztürk C, Friederich M, Werner N, et al. Single-center five-year outcomes after interventional edge-to-edge repair of the mitral valve. Cardiol J, 2021, 28(2): 215-222.
31.	Pascual I, Arzamendi D, Carrasco-Chinchilla F, et al. Transcatheter mitral repair according to the cause of mitral regurgitation: Real-life data from the Spanish MitraClip registry. Rev Esp Cardiol (Engl Ed), 2020, 73(8): 643-651.
32.	Patzelt J, Zhang W, Sauter R, et al. Elevated mitral valve pressure gradient is predictive of long-term outcome after percutaneous edge-to-edge mitral valve repair in patients with degenerative mitral regurgitation (MR), but not in functional MR. J Am Heart Assoc, 2019, 8(13): e011366.
33.	Perl L, Kheifets M, Guido A, et al. Acute reduction in left ventricular function following transcatheter mitral edge-to-edge repair. J Am Heart Assoc, 2023, 12(13): e029735.
34.	Rudolph V, Lubos E, Schlüter M, et al. Aetiology of mitral regurgitation differentially affects 2-year adverse outcomes after MitraClip therapy in high-risk patients. Eur J Heart Fail, 2013, 15(7): 796-807.
35.	Schueler R, Kaplan S, Melzer C, et al. Impact of interventional edge-to-edge repair on mitral valve geometry. Int J Cardiol, 2017, 230: 468-475.
36.	Seeger J, Müller P, Gonska B, et al. Percutaneous mitral valve repair with the MitraClip in primary compared with secondary mitral valve regurgitation using the mitral valve academic research consortium criteria. J Invas Cardiol, 2017, 29(4): 145-50.
37.	Yoon SH, Makar M, Kar S, et al. Outcomes after transcatheter edge-to-edge mitral valve repair according to mitral regurgitation etiology and cardiac remodeling. JACC Cardiovasc Interv, 2022, 15(17): 1711-1722.
38.	Goliasch G, Bartko PE, Pavo N, et al. Refining the prognostic impact of functional mitral regurgitation in chronic heart failure. Eur Heart J, 2018, 39(1): 39-46.
39.	Mack MJ, Lindenfeld J, Abraham WT, et al. 3-year outcomes of transcatheter mitral valve repair in patients with heart failure. J Am Coll Cardiol, 2021, 77(8): 1029-1040.
40.	Yeo KK, Yap J, Yamen E, et al. Percutaneous mitral valve repair with the MitraClip: early results from the MitraClip Asia-Pacific Registry (MARS). EuroIntervention, 2014, 10(5): 620-625.
41.	Tay E, Muda N, Yap J, et al. The MitraClip Asia-Pacific registry: Differences in outcomes between functional and degenerative mitral regurgitation. Catheter Cardiovasc Interv, 2016, 87(7): E275-281.
42.	Franzen O, van der Heyden J, Baldus S, et al. MitraClip® therapy in patients with end-stage systolic heart failure. Eur J Heart Fail, 2011, 13(5): 569-576.
43.	He S, Fontaine AA, Schwammenthal E, et al. Integrated mechanism for functional mitral regurgitation: leaflet restriction versus coapting force: in vitro studies. Circulation, 1997, 96(6): 1826-1834.
44.	He S, Lemmon JD, Jr. , Weston MW, et al. Mitral valve compensation for annular dilatation: in vitro study into the mechanisms of functional mitral regurgitation with an adjustable annulus model. J Heart Valve Dis, 1999, 8(3): 294-302.
45.	Kono T, Sabbah HN, Rosman H, et al. Left ventricular shape is the primary determinant of functional mitral regurgitation in heart failure. J Am Coll Cardiol, 1992, 20(7): 1594-1598.
46.	Raposeiras-Roubin S, Adamo M, Freixa X, et al. A score to assess mortality after percutaneous mitral valve repair. J Am Coll Cardiol, 2022, 79(6): 562-573.
47.	Eggebrecht H, Schelle S, Puls M, et al. Risk and outcomes of complications during and after MitraClip implantation: Experience in 828 patients from the German TRAnscatheter mitral valve interventions (TRAMI) registry. Catheter Cardiovasc Interv, 2015, 86(4): 728-735.
48.	荆朝辉, 荣晓松, 焦国庆, 等. 合并重度肺动脉高压的二尖瓣疾病行二尖瓣置换术的安全性. 国际心血管病杂志, 2024, 51(1): 62-64.
49.	Chan KL, Chen SY, Chan V, et al. Functional significance of elevated mitral gradients after repair for degenerative mitral regurgitation. Circ Cardiovasc Imaging, 2013, 6(6): 1041-1047.

1. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: A population-based study. Lancet, 2006, 368(9540): 1005-1011.
2. Trichon BH, Felker GM, Shaw LK, et al. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol, 2003, 91(5): 538-543.
3. Hu P, Liu XB, Liang J, et al. A hospital-based survey of patients with severe valvular heart disease in China. Int J Cardiol, 2017, 231: 244-247.
4. 叶蕴青, 许海燕, 李喆, 等. 中国不同区域老年瓣膜性心脏病构成和病因分析. 中华老年心脑血管病杂志, 2019, 21(7): 676-682.
5. 潘文志, 周达新, 葛均波. 中国二尖瓣反流患者人群数量的估测. 中国胸心血管外科临床杂志, 2021, 28(5): 495-498.
6. 潘翠珍, 潘文志, 周达新. 二尖瓣反流介入治疗的超声心动图评价中国专家共识. 中国介入心脏病学杂志, 2019, 27(1): 6-12.
7. 陈涛, 于波. 经导管二尖瓣缘对缘修复术在二尖瓣反流中的应用进展. 华西医学, 2023, 38(9): 1281-1287.
8. Head SJ, van Leeuwen WJ, Van Mieghem NM, et al. Surgical or transcatheter mitral valve intervention: complex disease requires complex decisions. EuroIntervention, 2014, 9(10): 1133-1135.
9. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J, 2017, 38(36): 2739-2791.
10. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 2017, 135(25): e1159-e1195.
11. Sorajja P, Vemulapalli S, Feldman T, et al. Outcomes with transcatheter mitral valve repair in the United States: An STS/ACC TVt registry report. J Am Coll Cardiol, 2017, 70(19): 2315-2327.
12. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e35-e71.
13. Mauri L, Foster E, Glower DD, et al. 4-year results of a randomized controlled trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol, 2013, 62(4): 317-328.
14. Baldus S, Schillinger W, Franzen O, et al. MitraClip therapy in daily clinical practice: Initial results from the German transcatheter mitral valve interventions (TRAMI) registry. Eur J Heart Fail, 2012, 14(9): 1050-1055.
15. Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: Early and 1-year results from the ACCESS-EU, a prospective, multicenter, nonrandomized post-approval study of the MitraClip therapy in Europe. J Am Coll Cardiol, 2013, 62(12): 1052-1061.
16. Grasso C, Capodanno D, Scandura S, et al. One- and twelve-month safety and efficacy outcomes of patients undergoing edge-to-edge percutaneous mitral valve repair (from the GRASP Registry). Am J Cardiol, 2013, 111(10): 1482-1487.
17. Nickenig G, Estevez-Loureiro R, Franzen O, et al. Percutaneous mitral valve edge-to-edge repair: in-hospital results and 1-year follow-up of 628 patients of the 2011-2012 Pilot European Sentinel Registry. J Am Coll Cardiol, 2014, 64(9): 875-884.
18. Bonow RO, Carabello B, de Leon AC, et al. ACC/AHA guidelines for the management of patients with valvular heart disease. Executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). J Heart Valve Dis, 1998, 7(6): 672-707.
19. Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med, 2018, 379(24): 2307-2318.
20. Bavry AA, Arnaoutakis GJ. Perspective to 2020 American College of Cardiology/American Heart Association (ACC/AHA) guideline for the management of patients with valvular heart disease. Circulation, 2021, 143(5): 407-409.
21. Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med, 2011, 364(15): 1395-1406.
22. Liu XH, Shi JY, Feng XJ, et al. Short-term and 1-year outcomes after MitraClip therapy in functional versus degenerative mitral regurgitation patients: a systematic review and meta-analysis. J Thorac Dis, 2018, 10(7): 4156-4168.
23. Chiarito M, Pagnesi M, Martino EA, et al. Outcome after percutaneous edge-to-edge mitral repair for functional and degenerative mitral regurgitation: A systematic review and meta-analysis. Heart, 2018, 104(4): 306-312.
24. Søndergaard L, Steinbrüchel DA, Ihlemann N, et al. Two-year outcomes in patients with severe aortic valve stenosis randomized to transcatheter versus surgical aortic valve replacement: The all-comers nordic aortic valve intervention randomized clinical trial. Circ Cardiovasc Interv, 2016, 9(6): e003665.
25. Cota GF, de Sousa MR, Fereguetti TO, et al. Efficacy of anti-leishmania therapy in visceral leishmaniasis among HIV infected patients: A systematic review with indirect comparison. PLoS Negl Trop Dis, 2013, 7(5): e2195.
26. Henández-Vaquero D, Pascual I, Almendarez M, et al. Initial experience of a MitraClip valve repair program in Spain. Ann Transl Med, 2020, 8(15): 957.
27. Kar S, von Bardeleben RS, Rottbauer W, et al. Contemporary outcomes following transcatheter edge-to-edge repair: 1-year results from the EXPAND study. JACC Cardiovasc Interv, 2023, 16(5): 589-602.
28. Kheifets M, Angelini F, D'Ascenzo F, et al. Outcomes of transcatheter edge-to-edge repair in degenerative vs. functional mitral regurgitation. J Clin Med, 2022, 11(20): 6010.
29. Mantegazza V, Pasquini A, Agati L, et al. Comprehensive assessment of mitral valve geometry and cardiac remodeling with 3-dimensional echocardiography after percutaneous mitral valve repair. Am J Cardiol, 2018, 122(7): 1195-1203.
30. Öztürk C, Friederich M, Werner N, et al. Single-center five-year outcomes after interventional edge-to-edge repair of the mitral valve. Cardiol J, 2021, 28(2): 215-222.
31. Pascual I, Arzamendi D, Carrasco-Chinchilla F, et al. Transcatheter mitral repair according to the cause of mitral regurgitation: Real-life data from the Spanish MitraClip registry. Rev Esp Cardiol (Engl Ed), 2020, 73(8): 643-651.
32. Patzelt J, Zhang W, Sauter R, et al. Elevated mitral valve pressure gradient is predictive of long-term outcome after percutaneous edge-to-edge mitral valve repair in patients with degenerative mitral regurgitation (MR), but not in functional MR. J Am Heart Assoc, 2019, 8(13): e011366.
33. Perl L, Kheifets M, Guido A, et al. Acute reduction in left ventricular function following transcatheter mitral edge-to-edge repair. J Am Heart Assoc, 2023, 12(13): e029735.
34. Rudolph V, Lubos E, Schlüter M, et al. Aetiology of mitral regurgitation differentially affects 2-year adverse outcomes after MitraClip therapy in high-risk patients. Eur J Heart Fail, 2013, 15(7): 796-807.
35. Schueler R, Kaplan S, Melzer C, et al. Impact of interventional edge-to-edge repair on mitral valve geometry. Int J Cardiol, 2017, 230: 468-475.
36. Seeger J, Müller P, Gonska B, et al. Percutaneous mitral valve repair with the MitraClip in primary compared with secondary mitral valve regurgitation using the mitral valve academic research consortium criteria. J Invas Cardiol, 2017, 29(4): 145-50.
37. Yoon SH, Makar M, Kar S, et al. Outcomes after transcatheter edge-to-edge mitral valve repair according to mitral regurgitation etiology and cardiac remodeling. JACC Cardiovasc Interv, 2022, 15(17): 1711-1722.
38. Goliasch G, Bartko PE, Pavo N, et al. Refining the prognostic impact of functional mitral regurgitation in chronic heart failure. Eur Heart J, 2018, 39(1): 39-46.
39. Mack MJ, Lindenfeld J, Abraham WT, et al. 3-year outcomes of transcatheter mitral valve repair in patients with heart failure. J Am Coll Cardiol, 2021, 77(8): 1029-1040.
40. Yeo KK, Yap J, Yamen E, et al. Percutaneous mitral valve repair with the MitraClip: early results from the MitraClip Asia-Pacific Registry (MARS). EuroIntervention, 2014, 10(5): 620-625.
41. Tay E, Muda N, Yap J, et al. The MitraClip Asia-Pacific registry: Differences in outcomes between functional and degenerative mitral regurgitation. Catheter Cardiovasc Interv, 2016, 87(7): E275-281.
42. Franzen O, van der Heyden J, Baldus S, et al. MitraClip® therapy in patients with end-stage systolic heart failure. Eur J Heart Fail, 2011, 13(5): 569-576.
43. He S, Fontaine AA, Schwammenthal E, et al. Integrated mechanism for functional mitral regurgitation: leaflet restriction versus coapting force: in vitro studies. Circulation, 1997, 96(6): 1826-1834.
44. He S, Lemmon JD, Jr. , Weston MW, et al. Mitral valve compensation for annular dilatation: in vitro study into the mechanisms of functional mitral regurgitation with an adjustable annulus model. J Heart Valve Dis, 1999, 8(3): 294-302.
45. Kono T, Sabbah HN, Rosman H, et al. Left ventricular shape is the primary determinant of functional mitral regurgitation in heart failure. J Am Coll Cardiol, 1992, 20(7): 1594-1598.
46. Raposeiras-Roubin S, Adamo M, Freixa X, et al. A score to assess mortality after percutaneous mitral valve repair. J Am Coll Cardiol, 2022, 79(6): 562-573.
47. Eggebrecht H, Schelle S, Puls M, et al. Risk and outcomes of complications during and after MitraClip implantation: Experience in 828 patients from the German TRAnscatheter mitral valve interventions (TRAMI) registry. Catheter Cardiovasc Interv, 2015, 86(4): 728-735.
48. 荆朝辉, 荣晓松, 焦国庆, 等. 合并重度肺动脉高压的二尖瓣疾病行二尖瓣置换术的安全性. 国际心血管病杂志, 2024, 51(1): 62-64.
49. Chan KL, Chen SY, Chan V, et al. Functional significance of elevated mitral gradients after repair for degenerative mitral regurgitation. Circ Cardiovasc Imaging, 2013, 6(6): 1041-1047.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesEfficacy of Mitraclip in functional versus degenerative mitral regurgitation: A systematic review and meta-analysis

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