Outcomes of left ventricular assist device implantation following previous mitral transcatheter edge-to-edge repair

Background: Mitral transcatheter edge-to-edge repair (M-TEER) has improved outcomes in selected patients with secondary mitral regurgitation (MR). However, patients can experience progressive heart failure (HF), subsequently requiring durable mechanical support with left ventricular assist devices (LVAD). Optimal management strategies for M-TEER devices during LVAD implantation remain unclear. Methods: This retrospective multicenter study included consecutive patients who underwent LVAD implantation following prior M-TEER for secondary MR at three tertiary Italian centers (2012-2022). Patients were categorized based on clip management during LVAD surgery: surgical removal, retention with elevated residual mitral gradient (>= 5 mmHg), or retention with normal gradient (<5 mmHg). The primary endpoint was a composite of all-cause mortality or HF hospitalization. Results: A total of 28 patients were included, with a median age of 64 years; 86% were male. Median interval from M-TEER to LVAD implantation was 378 days. Clip removal was performed in 5 patients (18%), while 23 (82%) retained the clip (3 with elevated and 20 with normal gradients). MR improved significantly post-LVAD implantation in all groups. In-hospital mortality was 11%, higher (40%) in patients undergoing clip removal. At a median follow-up of 35 months, the composite endpoint occurred in 63% of patients without significant differences between groups (p = 0.60). Conclusions: LVAD implantation following M-TEER therapy is feasible, with acceptable perioperative and mid-term outcomes. Retaining the clip is safe, particularly if residual MV gradients are low.