https://doi.org/10.1007/s00392-025-02625-4
1Herzzentrum Leipzig - Universität Leipzig Universitätsklinik für Herzchirurgie Leipzig, Deutschland; 2Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland
Aims
Surgical mitral valve repair (sMVR) and mitral valve transcatheter edge to edge repair (M-TEER) are common treatments in patients with symptomatic severe primary mitral regurgitation. The aim of this study was to investigate procedural safety, efficacy and clinical outcomes of both techniques in patients with degenerative mitral regurgitation.
Methods and Results
591 patients with symptomatic severe primary mitral regurgitation were included in this monocentric retrospective observational study between 2009 and 2024. 260 patients were treated with M-TEER and 331 patients underwent sMVR (44% vs. 56%). Patients with an age less than 60 years and/or with diagnosis of endocarditis were excluded. Primary endpoints were 30-day mortality and estimated 1-year mortality by Kaplan-Meier analysis. Secondary endpoints were procedural success, complications and effectiveness in terms of reduction of mitral regurgitation assessed by echocardiography.
Patient age in the M-TEER group was significantly higher compared to patients who underwent sMVR (median age 81 [IQR 77; 84] vs. median age 68 years [ 64; 73], p<0.001). Further baseline characteristics like incidence of coronary artery disease (37.6% [N=97] vs. 16.7% [N=55], p<0.001), diabetes mellitus (24.6% [N=64] vs. 10.3% [N=34], p<0.001), atrial fibrillation (64.9% [N=168] vs 35.3% [N=116], p<0.001) and chronic kidney disaese (42.1% [N=109] vs. 13.3% [N=44], p<0.001) where significantly higher in the M-TEER group.
Aetiologies of primary mitral regurgitation were predominantly anterior and posterior mitral leaflet prolapse in both groups (M-TEER 86.8% [N=225] vs. sMVR 90% [N=298]; p=n. s.). A higher incidence of barlow’s disease was present in the M-TEER group (6.54% [N=18] vs. 0.91% [N=3], p<0.001). Left ventricular ejection fraction (LVEF) was comparable in both groups (60% vs. 62%). Pre-interventional grade of mitral regurgitation grade >2 accounted for 100% in the M-TEER group (N=260) and 85.4% (N=281) in sMVR group (p<0.001).
Procedural and surgical success, defined as mitral regurgitation grade <2 was high in the investigated groups (66% [N=159] vs. 98.1% [N=319], p<0.001). More patients after sMVR had no residual MR at discharge (7.47% [N=260] vs. 69.5% [N=226], p<0.001). LVEF (54% vs. 56%) and mean MV gradient (2.6 mmHg vs. 3.3 mmHg) did not differ significantly between the groups. There was no significant difference regarding 30 day mortality (2.0% [N=4] vs. 1.3% [N=4], p=0.72). At the 1-year follow up mortality rates began to show a significant difference between the groups (11.2% [N=15] vs. 3.1% [N=9], p=0.002). This finding was repeatedly found after 3 and 5 year follow up (3 year mortality: 40.6% [N=26] vs. 6.4% [N=16], p<0.001; 5 year mortality: 65.9% [N=29] vs. 11.8% [N=27], p<0.001).
Conclusion
In patients with primary mitral regurgitation treatment with sMVR and M-TEER are effective and safe with comparable outcomes. Survival data show a better outcome in patients undergoing sMVR most likely attributed to the fitter patient collective opted for surgery. In the age-matched cohort mortality rates begin to differ later compared to the unmatched cohort. The comparison regarding mortality analysis is only partially applicable due to the observational study design.
The currently enrolling randomized controlled trials will broaden our understanding of causal mechanisms in outcome differences between surgical and percutaneous mitral valve repair.