Real-world outcomes after simplified mitral valve transcatheter edge-to-edge repair under sole transesophageal echocardiographic guidance

OBJECTIVE A simplified mitral valve transcatheter edge-to-edge repair (M-TEER) workflow under sole transesophageal echocardiographic (TEE) guidance, without fluoroscopy, has been developed. This study aimed to compare its real-world outcomes with the conventional procedures under the combined guidance of fluoroscopy and TEE. METHODS We retrospectively analyzed 386 patients undergoing M-TEER between January 2021 and December 2025, including 286 in the Sole-TEE guidance group and 100 in the Combined guidance group. The primary endpoints were cardiovascular mortality, all-cause mortality, and a composite of all-cause mortality and heart failure hospitalization. Propensity score matching and overlap weighting were performed as sensitivity analyses. RESULTS Technical success was achieved in 98.3% and 97.0% of patients in the Sole-TEE and Combined guidance groups, respectively, and 30-day major adverse events occurred in 2.8% and 7.0%, respectively (p > 0.05). The median follow-up was 16.5 months. At 1 year, the estimated cumulative incidence rates of the three primary endpoints were 4.4%, 6.0%, and 11.3% in the Sole-TEE guidance group and 6.4%, 8.5%, and 11.3% in the Combined guidance group, respectively (p > 0.05). M-TEER failure at 1 year was 4.8% and 6.3%, respectively (p > 0.05). The corresponding adjusted hazard ratios (95% confidence intervals) for the three primary endpoints were 1.52 (0.61-3.79), 0.96 (0.42-2.18), and 0.93 (0.48-1.81), respectively. Findings were consistent in sensitivity and subgroup analyses. CONCLUSIONS In this real-world observational cohort, M-TEER performed under sole-TEE guidance was associated with favorable procedural and follow-up outcomes, supporting the feasibility of this simplified workflow in experienced centers.