Pulmonary arterial systolic pressure evolution after transcatheter edge-to-edge mitral valve repair and its association with outcomes

Background/Introduction Transcatheter edge-to-edge repair (TEER) is the treatment of choice for high-surgical-risk patients with severe mitral regurgitation (MR). While persistent pulmonary hypertension (PH) predicts adverse outcomes after mitral valve surgery, its prognostic impact after TEER remains incompletely defined. Purpose To evaluate early changes in systolic pulmonary arterial pressure (sPAP) following TEER and their association with long-term outcomes. Methods This multicenter international retrospective cohort study included 378 patients who underwent TEER between December 2012 and January 2023 across four centers. sPAP was measured by transthoracic echocardiography before the procedure and on day 1 post-TEER. PH was defined as sPAP >50 mmHg pre-TEER and >40 mmHg post-TEER. Patients were stratified into four groups: No PH, New PH, Normalized PH, and Persistent PH. The primary endpoint was a composite of all-cause mortality, heart failure hospitalization, or mitral valve reintervention. Results Median age was 80 years (IQR 74–85), and 57% were women. One hundred and sixty nine patients (46%) had degenerative mitral regurgitation. Baseline PH was present in 149 patients (39%). After TEER, 139 (37%) had No PH, 90 (24%) New PH, 48 (13%) Normalized PH, and 101 (27%) Persistent PH. Elevated post-TEER sPAP (aHR 2.0, 95% CI 1.4–2.9, p<0.01), residual MR ≥ moderate (aHR 2.9, 95% CI 1.8–4.5, p<0.01), and EuroSCORE II (aHR 1.1, 95% CI 1.0–1.1, p<0.01) independently predicted adverse events. A spline curve of the hazard ratio for the primary endpoint as a function of post-TEER sPAP (Figure 1) demonstrated a marked increase in risk above 40 mmHg. Event rates differed significantly across groups (Figure 2): compared with Persistent PH, Normalized PH (HR 0.28, 95% CI 0.15–0.54, p<0.01) and No PH (HR 0.49, 95% CI 0.33–0.73, p<0.01) were associated with lower risk, whereas New PH showed similar outcomes (HR 0.98, 95% CI 0.67–1.46, p=0.95). Chronic lung disease (aOR 3.5, 95% CI 0.9–13.2, p=0.04) and baseline NYHA class III–IV (aOR 0.4, 95% CI 0.2–1.0, p=0.04) were associated with persistent PH. Degenerative MR independently predicted new-onset PH (aOR 4.6, 95% CI 1.7–12.8, p<0.01). Conclusion(s) Early reduction in sPAP after TEER is independently associated with improved long-term outcomes. Routine post-procedural sPAP assessment provides incremental prognostic value and should be systematically integrated into post-TEER echocardiographic evaluation.