Periprocedural Pulmonary Hypertension and Outcomes After Mitral Valve Transcatheter Edge-to-Edge Repair

BACKGROUND: Pulmonary hypertension (PH) is common in patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER), but the prognostic significance of periprocedural PH changes remains uncertain. OBJECTIVES: This study sought to evaluate the association between periprocedural PH patterns and clinical outcomes after M-TEER and to identify predictors of residual and new-onset PH. METHODS: The OCEAN-Mitral registry prospectively enrolled 3,764 patients with severe mitral regurgitation treated with M-TEER. Among 3,484 patients with paired echocardiographic tricuspid regurgitation pressure gradient (TRPG) data, PH was defined as TRPG >31 mm Hg. Patients were classified as having no PH, normalized PH, new-onset PH, or residual PH according to pre- and postprocedural PH status. The primary endpoint was 2-year cardiovascular death or heart failure hospitalization. Multivariable logistic regression identified predictors of residual and new-onset PH. RESULTS: No PH was observed in 1,432 patients (41.1%), normalized PH in 763 (21.9%), new-onset PH in 298 (8.6%), and residual PH in 991 (28.4%). The 2-year incidence of the primary endpoint differed significantly across groups (17.6%, 18.1%, 27.2%, and 27.6%, respectively; P < 0.001). Normalized PH showed outcomes comparable to no PH (adjusted HR: 0.98; 95% CI: 0.78-1.24). In contrast, new-onset PH (HR: 1.46; 95% CI: 1.10-1.93) and residual PH (HR: 1.37; 95% CI: 1.13-1.68) were independently associated with adverse outcomes. Severe tricuspid regurgitation, baseline TRPG >50 mm Hg, and tricuspid annular dilation predicted residual PH, whereas residual mitral regurgitation and postprocedural transmitral gradients >5 mm Hg predicted new-onset PH. CONCLUSIONS: Periprocedural PH dynamics provide robust risk stratification after M-TEER, identifying low-risk patients with PH normalization and high-risk subsets with residual or new-onset PH, requiring closer surveillance and procedural optimization. Registration Treatment and Prognosis of Heart Valve Registry; UMIN-ID: UMIN000023653.