Echocardiographic Assessment of Prognosis and Treatment Benefit After Mitral Transcatheter Edge‐to‐Edge Repair
Ehsan Shahverdi, Mahkameh Rasouli, Ramtin Keshavarzi, Carsten Schneider, Mathias LangeABSTRACT
Background
Mitral transcatheter edge‐to‐edge repair (TEER) can achieve substantial mitral regurgitation (MR) reduction in appropriately selected patients, yet outcomes after technically successful intervention remain heterogeneous. This variability has prompted interest in echocardiographic markers of limited treatment benefit. However, adverse prognosis after TEER and absence of benefit attributable to TEER are fundamentally different concepts, and most available imaging studies evaluate the former rather than the latter.
Methods
This state‐of‐the‐art review summarizes evidence on echocardiographic assessment of prognosis and treatment response across the mitral TEER pathway, integrating baseline multichamber phenotyping, procedural and immediate hemodynamic assessment, longitudinal imaging, and evidence from randomized trials of TEER in secondary MR.
Results
Baseline left ventricular remodeling and myocardial dysfunction, left atrial disease, pulmonary hypertension, right ventricular dysfunction and right ventricular–pulmonary arterial uncoupling, and tricuspid regurgitation identify greater cardiovascular disease burden and residual risk after TEER. Procedural assessment extends beyond residual MR to include transmitral pressure gradient, forward flow, and left atrial hemodynamics, whereas serial imaging characterizes subsequent ventricular, atrial, pulmonary, and right‐heart trajectories. Persistent structural or hemodynamic abnormalities and absence of reverse remodeling should not be equated with irreversible disease or therapeutic futility. Randomized subgroup analyses in secondary MR have not consistently demonstrated significant treatment‐effect modification by several adverse echocardiographic phenotypes; however, these analyses were not adequately powered to exclude clinically meaningful interactions. Moreover, COAPT excluded patients with extreme ventricular remodeling, markedly elevated pulmonary pressures, or advanced RV dysfunction, limiting generalizability to these populations. Differences among COAPT, MITRA‐FR, and RESHAPE‐HF2 further caution against defining a universal echocardiographic treatment‐response phenotype.
Conclusions
Echocardiography is essential for defining MR mechanism and severity, characterizing multichamber cardiovascular disease, evaluating procedural results, and refining longitudinal risk assessment. However, current evidence does not establish a validated echocardiographic threshold or phenotype that reliably predicts absence of treatment benefit. Randomized subgroup findings require cautious interpretation because of limited statistical power and the exclusion of patients with the most advanced ventricular and pulmonary vascular disease. Future adequately powered comparative studies should evaluate heterogeneity of treatment effect across MR etiologies using standardized multichamber imaging and patient‐centered outcomes.