MitraClip for mitral regurgitation:
when it is used and how it works

Article written and reviewed by Dr Luca Moretti

MitraClip is one of the devices used to perform mitral TEER, or transcatheter edge-to-edge repair. The procedure brings part of the two mitral valve leaflets closer together to reduce backward blood flow, without opening the chest and without replacing the valve.
It is not, however, a suitable treatment for every case of mitral regurgitation. The choice depends on the mechanism of regurgitation, valve anatomy, symptoms, treatment already received and the risk of surgery.

To understand when a leaking valve requires treatment, it is useful first to distinguish the different forms of mitral regurgitation. TEER has a different role in primary and secondary mitral regurgitation.

How TEER with MitraClip works

The procedure is performed in a catheterization laboratory or hybrid operating room by a specialized team. The catheter is generally introduced through a femoral vein in the groin and advanced to the right atrium. A controlled puncture of the interatrial septum provides access to the left atrium and then to the mitral valve.
Under transesophageal echocardiographic and fluoroscopic guidance, the device is oriented over the area where the leaflets do not close properly.

The clip grasps the mitral leaflets and keeps them closer together during contraction of the heart. This reduces the area through which blood flows back into the left atrium. In some patients one device is sufficient; in others, more than one implant may be needed.
Before the procedure is completed, the team confirms that regurgitation has been reduced satisfactorily and that the narrowing created by the repair does not produce significant mitral stenosis.

When it is used in primary mitral regurgitation

In primary mitral regurgitation, the problem lies in the valve itself, for example in degenerative prolapse. If regurgitation is severe, the patient is operable and a durable surgical repair is expected, surgery remains the standard treatment.
The 2025 ESC/EACTS guidelines instead state that TEER should be considered in symptomatic patients with severe primary mitral regurgitation, suitable anatomy and high surgical risk according to Heart Team assessment.

This means that MitraClip is not simply a less invasive version of the same operation. Surgical repair allows more extensive interventions on the mitral apparatus, whereas TEER has the advantage of avoiding major cardiac surgery in patients for whom that risk carries substantial weight.

When it is used in secondary mitral regurgitation

In ventricular secondary mitral regurgitation, the valve leaks because a dilated or remodeled left ventricle prevents the leaflets from closing properly. Before considering TEER, heart failure therapy must therefore be optimized and cardiac resynchronization therapy used when indicated.
In some patients, regurgitation is already reduced by this treatment.

If the patient remains symptomatic with severe ventricular secondary regurgitation and favorable anatomy, TEER is recommended by the 2025 guidelines in patients with characteristics that make clinical benefit likely. Criteria used include symptoms of at least NYHA class II, ejection fraction between 20% and 50%, ventricular end-systolic diameter no greater than 70 mm, recent evidence of heart failure or increased natriuretic peptides, and absence of advanced conditions that would make benefit unlikely.

These numbers are not intended for patients to determine the indication on their own. They explain why two people with a similar percentage of mitral regurgitation may receive different treatment decisions.

Which tests are needed before the procedure

The key test is the echocardiogram. Transesophageal echocardiography, especially three-dimensional imaging, makes it possible to assess leaflet shape, the site of regurgitation, valve area and whether the leaflets can be grasped without creating excessive stenosis.
Left and right ventricular function, pulmonary pressure, other valve diseases, the coronary arteries when indicated and the patient’s general condition are also assessed.

The Heart Team combines these findings with surgical risk, life expectancy, frailty, previous procedures and the person’s preferences. Unfavorable anatomy can make the procedure ineffective even in a patient who would otherwise appear to be a good candidate because of age or comorbidities.

Benefits, limitations and possible complications

In selected ventricular secondary mitral regurgitation, randomized trials such as COAPT and RESHAPE-HF2 have shown that adding TEER to medical therapy can reduce heart failure hospitalizations and improve health status; COAPT also observed a survival benefit during follow-up. The MITRA-FR trial, by contrast, did not show the same benefit, underscoring the importance of patient selection.
The aim of the procedure is to reduce regurgitation significantly, not to guarantee that it disappears completely.

Like any invasive procedure, TEER can have complications. Possible complications include bleeding or vascular problems, pericardial effusion, stroke, partial detachment of the device from a leaflet, persistence of significant regurgitation or creation of an excessive mitral gradient. Anatomical assessment and center experience help reduce these risks.

After the procedure
The vascular access site, heart rhythm, echocardiogram and clinical course are monitored. Follow-up determines whether the reduction in regurgitation is maintained and whether symptoms and functional capacity improve.
Medications are not automatically discontinued: especially in secondary mitral regurgitation, heart failure therapy remains essential even after a technically successful procedure.

If new shortness of breath, edema, reduced exercise capacity or heart failure hospitalizations develop over time, the patient should be reassessed. Previous TEER does not absolutely prevent future procedures, but it can make subsequent surgery or another intervention more complex and must therefore be considered in the long-term strategy.

Frequently asked questions about MitraClip and TEER

What is the difference between MitraClip and TEER?
TEER is the transcatheter edge-to-edge repair technique. MitraClip is one of the systems used to perform it.

Who is eligible for MitraClip?
Eligibility depends on the type of regurgitation, symptoms, surgical risk, treatment already received and, above all, valve anatomy.

Does MitraClip replace surgery?
Not in all patients. In operable primary mitral regurgitation, surgery remains the standard; in selected ventricular secondary mitral regurgitation, TEER has a very important role.

How is it inserted?
Generally through a femoral vein, with access to the left atrium by puncture of the interatrial septum and positioning on the mitral valve under echocardiographic and fluoroscopic guidance.

Does mitral regurgitation always disappear?
No. The aim is to achieve a clinically significant reduction without creating significant mitral stenosis.