Transcatheter Mitral Valve Replacement in Atrial and Ventricular Secondary Mitral Regurgitation: Insights from the CHOICE-MI Registry

Clin Res Cardiol (2026). DOI 10.1007/s00392-026-02870-1
S. Ludwig (Hamburg)¹, P. von Stein (Köln)², J. Weimann (Hamburg)¹, A. Scotti (New York)³, A. Coisne (Lille)⁴, B. Köll (Hamburg)¹, W. Ben Ali (Montreal)⁵, M. Adam (Köln)², A. Duncan (London)⁶, J. G. Webb (Vancouver)⁷, M. Keßler (Ulm)⁸, G. Nickenig (Bonn)⁹, H. Ruge (München)¹⁰, N. Dumonteil (Toulouse)¹¹, O. De Backer (Copenhagen)¹², D. Regazzoli (Mailand)¹³, A. Garatti (Mailand)¹⁴, M. De Carlo (Pisa)¹⁵, M. Andreas (Wien)¹⁶, C. Frerker (Lübeck)¹⁷, G. Dahle (Oslo)¹⁸, M. Taramasso (Zürich)¹⁹, T. Walther (Frankfurt am Main)²⁰, J. Kempfert (Berlin)²¹, J.-F. Obadia (Lyon)²², S. Redwood (London)²³, G. H. L. Tang (New York)²⁴, M. Reardon (Houston)²⁵, N. Fam (Toronto)²⁶, F. Praz (Bern)²⁷, D. W. Muller (Darlinghurst, NSW)²⁸, P. Denti (Mailand)²⁹, P. Lurz (Mainz)³⁰, R. S. von Bardeleben (Mainz)³¹, J. Hausleiter (München)³², M. Adamo (Brescia)³³, V. Ninios (Thessaloniki)³⁴, T. K. Rudolph (Bad Oeynhausen)³⁵, A. Latib (New York)³, J. Granada (New York City)³⁶, T. Modine (Bordeaux)³⁷, L. Conradi (Köln)³⁸, C. Iliadis (Köln)^2
1Universitäres Herz- und Gefäßzentrum Klinik für Kardiologie Hamburg, Deutschland; ²Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ³Montefiore Medical Center Interventional Cardiology New York, USA; ⁴Heart Valve Clinic, CHU Lille Department of Clinical Physiology and Echocardiography Lille, Frankreich; ⁵Montreal Heart Institute Montreal, Kanada; ⁶Royal Brompton and Harefield Hospital Consultant Cardiologist London, Großbritannien; ⁷St. Paul’s Hospital, University of British Columbia Vancouver, Kanada; ⁸Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland; ⁹Universitätsklinikum Bonn Medizinische Klinik und Poliklinik II Bonn, Deutschland; ¹⁰Deutsches Herzzentrum München Klinik für Herz- und Gefäßchirurgie München, Deutschland; ¹¹Hospital Rangueil Pôle Cardiovasculaire et Métabolique, Toulouse, Frankreich; ¹²Rigshospitalet Copenhagen Cardiology Copenhagen, Dänemark; ¹³Humanitas Research Hospital Mailand, Italien; ¹⁴San Donato Hospital San Donato Hospital Mailand, Italien; ¹⁵Pisa University Hospital Pisa, Italien; ¹⁶Allgemeines Krankenhaus der Stadt Wien - Medizinischer Universitätscampus Klinik für Herzchirurgie Wien, Österreich; ¹⁷Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ¹⁸Rikshospitalet Oslo, Norwegen; ¹⁹HerzZentrum Hirslanden Zürich Zürich, Schweiz; ²⁰Universitätsklinikum Frankfurt Klinik für Thorax-, Herz- und Thorakale Gefäßchirurgie Frankfurt am Main, Deutschland; ²¹Deutsches Herzzentrum der Charite (DHZC) Klinik für Herz-, Thorax- und Gefäßchirurgie Berlin, Deutschland; ²²Louis Pradel Cardiologic Hospital Cardiology Lyon, Frankreich; ²³St. Thomas' Hospital Department of Cardiology London, Großbritannien; ²⁴Mount Sinai Hospital New York, USA; ²⁵Methodist DeBakey Heart and Vascular Center Houston, USA; ²⁶St. Michael's Hospital Division of Cardiology Toronto, Kanada; ²⁷Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ²⁸St Vincent's Private Hospital Sydney Darlinghurst, NSW, Australien; ²⁹I.R.C.C.S. Ospedale San Raffaele Cardiochirurgia Mailand, Italien; ³⁰Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland; ³¹Universitätsmedizin der Johannes Gutenberg-Universität Mainz Zentrum für Kardiologie im Herz- und Gefäßzentrum Mainz, Deutschland; ³²LMU Klinikum der Universität München Medizinische Klinik und Poliklinik I München, Deutschland; ³³University of Brescia Cardiac Catheterization Laboratory and Cardiology Brescia, Italien; ³⁴Thessaloniki, Griechenland; ³⁵Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ³⁶Cardiovascular Research Foundation New York City, USA; ³⁷Centre Hospitalier Universitaire Bordeaux Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle Bordeaux, Frankreich; ³⁸Universitätsklinikum Köln Klinik und Poliklinik für Herzchirurgie Köln, Deutschland

Background: Transcatheter mitral valve replacement (TMVR) has emerged as a novel therapeutic option for patients with mitral regurgitation (MR). In secondary MR (SMR), TMVR has demonstrated high technical success rates, significant and sustained MR reduction, and significant symptomatic relief. SMR comprises two phenotypes, atrial SMR (aSMR) and ventricular SMR (vSMR). Whether outcomes differ between patients undergoing TMVR for aSMR and vSMR remains unclear and is the focus of this analysis.

Methods: The CHOICE-MI study (NCT04688190) is an investigator-initiated, international, multicenter registry including consecutive patients with symptomatic MR treated with dedicated TMVR devices. This analysis included only those with SMR. aSMR was defined as left ventricular ejection fraction (LVEF) ≥40%, left ventricular end-diastolic volume ≤85ml/m² (male) or ≤78ml/m² (female), and left atrial volume index ≥40 mL/m2. The primary endpoint was MVARC-defined technical success. Secondary endpoints included change in NYHA class and the composite of all-cause mortality or hospitalization for heart failure (HF) within 2-years.

Results: Among 202 patients treated with TMVR for SMR (median age 76 [70-80] years; 40% female; 81% NYHA class ≥III, EuroSCORE II: 6.3 [3.9-14.0] %), 31 (15%) met criteria for aSMR and 171 (85%) for vSMR. Compred with vSMR, patients with aSMR were older (median 77 vs. 75 years; p=0.04) and tended to be more frequently female (55% vs. 37%; p=0.08) with similar symptom burden at baseline (NYHA class III/IV: 83.9% vs. 80.1%; p=0.81). TMVR was predominantly performed via a transapical approach in both groups (80.6% vs. 83.0%; p=0.80). Technical success was achieved in 90.3% (aSMR) and 97.1% (vSMR) (p=0.11). Residual MR of none/trace at discharge was observed in 92.3% of vSMR and 82.8% of vSMR patients (p=0.38). NYHA class improved significantly in both groups (p<0.001 vs. baseline), with 93.3% of aSMR and 83.5% of vSMR patients in NYHA ≤II at 1-year follow-up (p=0.74). The 2-year rate of all-cause death or HF hospitalization was similar between aSMR (45.3%) and vSMR (47.4%; p=0.92).

Conclusion: In this multicenter real-world cohort, TMVR yielded similarly high rates of technical success and symptomatic improvement in both aSMR and vSMR. Despite their distinct pathophysiology, clinical outcomes—including 2-year survival and freedom from HF hospitalization—were similar, supporting TMVR as a viable therapeutic strategy across the full spectrum of SMR.