An integrative approach to patient selection for mitral transcatheter edge-to-edge repair in secondary mitral regurgitation

PURPOSE OF REVIEW: Secondary mitral regurgitation (SMR) remains a major contributor to symptoms and hospitalizations in heart failure, despite guideline-directed medical therapy (GDMT). This review synthesizes current evidence and proposes a structured framework for identifying patients most likely to benefit from mitral transcatheter edge-to-edge repair (M-TEER), integrating data from randomized clinical trials, proportionality concepts, and multimodality imaging. RECENT FINDINGS: Divergent results in MITRA-FR and COAPT mainly reflect differences in echocardiographic selection and left-ventricular remodeling, which means SMR severity should be judged relative to ventricular size and regurgitant burden. Contemporary trials such as RESHAPE-HF2 and MATTERHORN broaden the evidence and support M-TEER in selected patients and as a safer alternative to surgery in some operable cohorts. Beyond effective regurgitant orifice area, regurgitant volume and regurgitant fraction better capture MR load. Cardiac magnetic resonance refines quantification when echocardiography is discordant or limited. Right-ventricular dysfunction and pulmonary vascular involvement are key modifiers of prognosis and expected benefit. SUMMARY: Optimal candidate selection requires a structured, integrative evaluation: confirm clinically meaningful SMR despite GDMT, ensure anatomic suitability, quantify severity with a multiparametric echo approach supplemented by CMR when indicated, and incorporate ventricular-atrial-pulmonary coupling. This physiology-based strategy moves beyond single thresholds to identify patients most likely to achieve meaningful clinical benefit.