Defining the limits of transcatheter valve repair: a prospective comparison of multivalvular interventions in the atrial fibrillation triad

Background

Atrial fibrillation and mitral regurgitation frequently coexist, creating a bidirectional cycle that accelerates atrial remodelling. This volume overload and arrhythmia burden readily extend to the right heart, driving tricuspid annular enlargement and functional tricuspid regurgitation.

Purpose

We evaluated a single-session strategy combining pulsed-field ablation and transcatheter edge-to-edge repair. We compared a dual intervention (ablation and mitral repair) against a triple intervention (adding tricuspid repair) to define invasive haemodynamic and structural outcomes in this complex patient population.

Methods

We prospectively enrolled ten consecutive high-surgical-risk patients with symptomatic atrial fibrillation and severe regurgitation. We performed all procedures via a single transseptal puncture. We compared the dual intervention (eight patients) and triple intervention (two patients) strategy groups, measuring procedure time, invasive left atrial pressures (measured in triplicate before and after repair), and echocardiographic parameters through six-month follow-up.

Results

We achieved procedural success in all ten cases. In the dual intervention group, mean left atrial pressure dropped from 13.8 to 12.1 millimetres of mercury, while peak v-waves fell from 22.0 to 18.8 millimetres of mercury. Acute mitral regurgitation reduction to moderate or less occurred in 88% of these cases. At six months, mean mitral regurgitation grade improved from 3.75 to 1.75, and functional class (New York Heart Association) improved from 2.88 to 1.75.

The triple intervention group exhibited a distinct advanced atrial phenotype. Despite severe regurgitation, these patients presented with lower baseline v-waves (mean 15.5 millimetres of mercury) than the dual group, reflecting extreme atrial compliance. In these patients, mean left atrial pressure shifted only from 12.5 to 10.5 millimetres of mercury. Massive geometric distortion (mean left atrial diameter 59.0 millimetres) prevented optimal mitral reduction; neither patient achieved moderate or less residual regurgitation. At six months, their mitral regurgitation grade remained largely unchanged (4.0 to 3.5), while functional class improved marginally from 2.5 to 2.0.

Conclusion(s)

A single-session strategy combining pulsed-field ablation and transcatheter edge-to-edge repair offers a feasible approach for early rhythm control and functional improvement. Our data suggest that the atrial fibrillation, mitral, and tricuspid regurgitation triad represents a late-stage phenotype driven by profound atrial remodelling. While dual interventions yield high structural success, massive baseline atrial dilatation—often masked by high atrial compliance and lower-than-expected v-waves—severely limits the efficacy of the clip and necessitates refined anatomical selection criteria.baseline characteristicsFor image description, please refer to the figure legend and surrounding text.