Dr Isida Byku (Structural Heart and Valve Center, Emory University Hospital, Atlanta, GA, US) discusses how the latest evidence for mitral transcatheter edge-to-edge repair (TEER) is informing patient selection and refining clinical practice.

How has the evidence base for mitral TEER evolved, and what are the most consequential recent findings for clinical practice?

The 2025 European Society of Cardiology guidelines make a clear distinction between functional atrial mitral regurgitation (MR) and functional ventricular MR. This has led to a significant upgrade in the recommendations for mitral TEER, particularly for patients with ventricular functional MR, where the therapy now carries a Class I, Level A recommendation.
This is an important step forward. Positioning mitral TEER alongside guideline-directed medical therapy as a core treatment option reflects the therapy’s proven ability to reduce heart failure hospitalisations and mortality while improving quality of life. Since the previous guideline update, two randomised controlled trials have demonstrated significant benefits in quality of life and reductions in heart failure hospitalisation rates, supporting the Class I, Level A recommendation.
For patients with atrial functional MR, the recommendation has also been strengthened to Class IIb. Expanded clinical studies have shown that these patients can derive substantial benefit from TEER, including more than a 50% reduction in heart failure hospitalisations and improvements of 19–20 points in Kansas City Cardiomyopathy Questionnaire (KCCQ) scores.
Overall, these guideline updates represent positive progress towards expanding access to mitral TEER for patients with both ventricular and atrial functional MR.

How does contemporary evidence inform patient selection across degenerative and functional mitral regurgitation?


For degenerative MR, surgical mitral valve repair remains the preferred treatment for patients who are suitable surgical candidates and have anatomy amenable to repair. However, emerging evidence continues to demonstrate excellent outcomes with mitral TEER in patients who are at high or prohibitive surgical risk.
The ability to offer a minimally invasive transcatheter option is highly valuable for these patients, and ongoing studies continue to explore the role of TEER in this population. At present, however, transcatheter repair remains primarily reserved for patients with degenerative MR who are unsuitable for surgery.
In contrast, for functional MR, transcatheter therapy has become a central component of management. Distinguishing between functional ventricular MR, functional atrial MR and degenerative MR is therefore essential when determining the most appropriate treatment strategy.

Which anatomical and physiological factors are most important when identifying patients likely to benefit from TEER?

High-quality imaging is fundamental to patient assessment. Detailed pre-procedural evaluation helps determine whether a patient is likely to benefit from TEER by examining factors such as leaflet motion, coaptation gap, the degree of leaflet tethering, left ventricular size and function, and left atrial dimensions.
Physiological assessment is equally important. Pulmonary pressures, invasive haemodynamics obtained through right heart catheterisation, overall haemodynamic compensation and volume status all contribute to decision-making.
Patient selection remains complex and dynamic. Shared decision-making with patients is essential and should remain central when discussing treatment options and determining the most appropriate pathway forward.

What role does the Heart Team play in navigating areas of clinical uncertainty and competing treatment options?

The Heart Team is at the centre of the evaluation and treatment process. Optimal decision-making requires close collaboration between structural heart specialists, cardiac surgeons, heart failure physicians and imaging experts.
In my practice, I first evaluate and counsel the patient in clinic. The case is then presented at a multidisciplinary Heart Team meeting, where colleagues from different specialties review the imaging and clinical data together before arriving at a consensus recommendation.
This recommendation is then discussed with the patient during a follow-up visit. Being able to explain that the treatment strategy has been reviewed and agreed upon by experts from multiple disciplines provides reassurance for both the physician and the patient.
The Heart Team approach also promotes engagement from all stakeholders involved in the patient’s care, not only during the procedure but throughout follow-up. Long-term success depends on optimisation of guideline-directed medical therapy and management of physiological factors that help sustain improvements in quality of life and reductions in heart failure hospitalisations.

How are device iteration and emerging data influencing procedural strategy and expected outcomes?

With each new device iteration, procedural success rates continue to improve. Devices are becoming more user-friendly, reliable and predictable, which shortens the learning curve for operators and facilitates wider adoption of the therapy.
Clinical data reflect these advances. Comparisons between third- and fourth-generation systems demonstrate that favourable outcomes are not only being maintained but continue to improve. Ongoing collaboration with industry partners is therefore important in further refining device technology, enhancing procedural performance and expanding access to treatment.
As devices become easier to use and outcomes continue to improve, operators gain greater confidence in adopting and advancing TEER techniques, ultimately benefiting a broader patient population.
What are your key take-home messages for clinicians applying contemporary mitral TEER evidence to patient selection?
The most important message from the 2025 European guidelines is the recognition of functional ventricular MR and functional atrial MR as distinct clinical entities, with corresponding upgrades in treatment recommendations. Mitral TEER now carries a Class I, Level A recommendation for ventricular functional MR and a Class IIb recommendation for atrial functional MR.
These recommendations are supported by a robust evidence base, including two randomised controlled trials in ventricular functional MR and expanding clinical data in atrial functional MR. Across both patient groups, TEER has demonstrated meaningful reductions in heart failure hospitalisations and significant improvements in quality of life.
Clinicians should focus on incorporating these updated recommendations into daily practice and prioritising earlier recognition and treatment of appropriate patients. Earlier intervention has the potential to help patients feel better, stay out of hospital and enjoy a better quality of life.