Impact of residual moderate mitral regurgitation after transcatheter edge-to-edge repair on long-term survival: insights from a multicenter cohort study

Background Transcatheter edge-to-edge mitral valve repair (mTEER) is an established treatment for patients with mitral regurgitation (MR) at prohibitive surgical risk. However, predictors of optimal MR reduction remain insufficiently defined. Methods We retrospectively analyzed all patients who underwent mTEER treatment at four German cardiac centers between 2011 and 2022. Patients were categorized by residual MR ≤ I° or II°. Univariable and multivariable logistic regression analyses revealed predictors of residual MR ≤ I°. Long-term survival was assessed via Kaplan–Meier analysis and adjusted through propensity-score matching (PSM). Results Among 821 patients, 724 (88.2%) achieved residual MR ≤ I°, whereas 97 (11.8%) achieved residual MR of II°. Patients with residual MR of II° were younger, exhibited higher morbidity, and required longer procedures with more clips. Age <65 years, prior implantable cardioverter defibrillator (ICD), and left ventricular end-diastolic diameter >62 mm served as inverse predictors of residual MR ≤ I° in univariable analysis. In contrast, only age <65 years remained a significant inverse predictor of residual MR ≤ I° in the multivariable model (odds ratio 0.39, 95% confidence interval 0.19–0.84, p = 0.01). Long-term survival did not differ significantly in the overall cohort between patients with residual MR ≤ I° and those with residual MR of II° before or after PSM. Conclusion Residual MR of II° occurred in 12% of patients and was more common in younger, comorbid individuals with complex MR anatomy. While survival was unaffected in the overall cohort, age <65 years emerged as a key predictor of suboptimal MR reduction. These findings highlight the need for critical patient selection and may inform individualized treatment strategies in contemporary mTEER practice.