Mitral Valve Surgery After Failed Transcatheter Edge-to-Edge Repair – A Meta-Analysis

Background Transcatheter edge-to-edge repair (TEER) is increasingly utilized for mitral regurgitation (MR), particularly in high-risk patients. However, when TEER fails, patients often require mitral valve surgery, which remains challenging due to patients' compromised condition. This study aims to evaluate short and long term surgical outcomes following failed TEER. Methods This meta-analysis included observational studies with reported outcomes of mitral valve surgery after failed TEER published until September 2024. Multivariable Meta-regressions were performed to predict short and long-term mortality. Kaplan-Meier function was reconstructed from individual studies. Results Sixteen studies were included with a total sample of 892 patients. The mean age was 74.8 years (55% males), with most patients (87.8%) in NYHA III/IV before surgery. Pooled mean STS-PROM score before indexed TEER was 6.3%. Surgical indications were recurrent MR ≥3+ (93%), mitral stenosis (17%), and endocarditis (2.7%). The average time between TEER and surgery was 6.4 months. Mitral valve replacement (MVR) was performed in 83.8% of cases. Thirty-day all-cause mortality was 12.2% but significantly lower for elective cases (2.5%). At a mean follow-up of 14.7 months, mortality was 28.3%. Preoperative incidence of CAD, lower LVEF, rate of concomitant procedures, and functional mitral regurgitation were predictors of short and long-term outcomes. Conclusion Mitral valve surgery after failed TEER presents significant challenges, yet acceptable outcomes are achievable, particularly in elective cases. Complete treatment of concomitant lesions may improve outcomes in patients with preserved LVEF. Future research should stratify outcomes based on emergent versus elective surgery and MR etiology to guide tailored surgical strategies.