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

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 (Sydney)²⁸, P. Denti (Milan)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 (Ney York)³⁶, J. Granada (New York)³⁷, T. Modine (Bordeaux)³⁸, L. Conradi (Köln)³⁹, C. Iliadis (Köln)^2
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; ²Herzzentrum der Universität zu Köln Klinik III für Innere Medizin Köln, Deutschland; ³Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care 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; ¹¹Clinique Pasteur Toulouse, Frankreich; ¹²University hospital Copenhagen Copenhagen, Dänemark; ¹³Humanitas Research Hospital Mailand, Italien; ¹⁴San Donato Hospital Mailand, Italien; ¹⁵Azienda Ospedaliero-Universitaria Pisana Cardiothoracic and Vascular Department Pisa, Italien; ¹⁶Medical University Vienna Wien, Österreich; ¹⁷Universitätsklinikum Schleswig-Holstein Medizinische Klinik II / Kardiologie, Angiologie, Intensivmedizin Lübeck, Deutschland; ¹⁸Rikshospitalet Oslo, Norwegen; ¹⁹HerzZentrum Hirslanden Cardiology 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; ²²Civils Hospices of Lyon Lyon, Frankreich; ²³St. Thomas' Hospital Department of Cardiology London, Deutschland; ²⁴Mount Sinai Hospital New York, USA; ²⁵Houston Methodist Hospital Houston, USA; ²⁶St. Michael's Hospital Toronto, Kanada; ²⁷Inselspital - Universitätsspital Bern Universitätsklinik für Kardiologie Bern, Schweiz; ²⁸St. Vincent's Hospital Sydney, Australien; ²⁹San Raffaele Hospital IRCCS Ospedale San Raffaele Milan, 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 Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health Brescia, Italien; ³⁴Thessaloniki, Griechenland; ³⁵Herz- und Diabeteszentrum NRW Allgemeine und Interventionelle Kardiologie/Angiologie Bad Oeynhausen, Deutschland; ³⁶Montefiore Medical Center, Albert Einstein College of Medicine Montefiore-Einstein Center for Heart and Vascular Care Ney York, USA; ³⁷Cardiovascular Research Foundation New York, Deutschland; ³⁸Centre Hospitalier Universitaire Bordeaux Service Médico-Chirurgical: Valvulopathies-Chirurgie Cardiaque-Cardiologie Interventionelle Structurelle Bordeaux, Frankreich; ³⁹Universitätsklinikum 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.