Echocardiographic markers of residual pulmonary vascular disease and clinical risk after transcatheter mitral valve edge-to-edge repair

Background Pulmonary hypertension (PH) is common in patients with chronic mitral regurgitation (MR) and advanced left-sided heart failure (HF) undergoing transcatheter mitral valve edge-to-edge repair (mTEER). While mTEER effectively reduces left atrial (LA) pressure and MR severity, a substantial subset of patients exhibit persistent PH and remain at elevated risk for adverse outcomes. The contribution of pulmonary vascular remodeling, reflected by pulmonary vascular resistance (PVR) and pulmonary artery systolic pressure (PASP), to this residual risk remains uncertain Objectives To evaluate whether echocardiographically-derived markers of pulmonary vascular disease, including right ventricular systolic pressure (RVSP) as a surrogate for PASP, and noninvasively estimated PVR, can identify patients at increased risk of heart failure (HF) hospitalization and death following mTEER Methods We performed a retrospective analysis of consecutive patients undergoing mTEER between January 2021 and August 2024. PH was defined as RVSP ≥50 mmHg. Additionally, PVR was estimated noninvasively using peak tricuspid regurgitation (TR) velocity and right ventricular outflow tract velocity time integral (RVOT-VTI) measurements from echocardiography. Elevated PVR was defined as ≥2 WU. We examined the prognostic impact of baseline and post-procedural metrics on a composite endpoint of all-cause mortality and HF hospitalization at 1 year Results Among 184 patients undergoing mTEER, PH was present in 167 patients (91%). Baseline PH was not independently associated with adverse clinical outcomes. However, residual post-procedural PH was associated with a significantly increased risk of the composite endpoint (hazard ratio [HR] 2.55, 95% confidence interval [CI] 1.06–6.17; log-rank p = 0.031). Similarly, persistently elevated echocardiographically-derived PVR was strongly associated with elevated risk of the primary endpoint (HR 2.41, 95% CI 1.13–5.12; log-rank p = 0.021). Patients with residual PH demonstrated higher rates of HF hospitalization (31.9% vs 18%). Impaired right ventricular–pulmonary arterial (RV-PA) coupling, defined by TAPSE/RVSP <0.36, was additionally associated with a numerically higher risk of the composite endpoint compared with preserved coupling (42.5% vs 32%) Conclusions Residual PH and persistently elevated Doppler echocardiographically-derived PVR following mTEER were independently associated with increased risk of HF hospitalization and mortality at 1 year. These findings suggest that pulmonary vascular remodeling phenotype, rather than isolated post-capillary pressure overload, contributes to residual risk after MR correction. Echocardiography provides a practical, noninvasive approach to post-mTEER risk stratification and longitudinal assessment. Prospective studies are needed to assess whether echocardiography-guided identification of residual pulmonary vascular disease may inform post-mTEER management and clinical outcomes.