Atrial fibrillation ablation versus transcatheter edge-to-edge mitral valve repair as first-line therapy in atrial fibrillation with functional mitral regurgitation

Abstract Background and Aim Atrial fibrillation (AF) and functional mitral regurgitation (FMR) frequently coexist and are linked through shared mechanisms of atrial and ventricular remodeling. Both catheter ablation and transcatheter edge-to-edge mitral valve repair (M-TEER) improve clinical status, yet the optimal sequence of these interventions remains unclear. This study evaluates real-world outcomes in patients with AF and FMR, comparing catheter ablation and M-TEER as initial strategies, with focus on MR severity, symptom stability, mortality, and hospitalization. Methods We conducted a single-center retrospective analysis of patients with AF and moderate to moderate-to-severe FMR. Patients were grouped according to the initial treatment strategy: AF ablation or M-TEER. Clinical and echocardiographic data were reviewed at baseline and follow-up. A retrospective two-year follow-up was performed to evaluate changes in mitral regurgitation severity, symptom stability, mortality, and hospitalization. Results A total of 281 patients were included (129 M-TEER, 152 AF ablation). MR severity improved more frequently following M-TEER (p < 0.001). However, AF ablation was associated with better symptom stability (69% vs. 44%, p < 0.001), markedly lower all-cause mortality (3% vs. 14%, p= 0.002), less all-cause cardiac hospitalizations (p = 0.021), and significant improvment in left ventricular ejection fraction at follow-up (53 ± 11.1%vs. 47 ± 13.9%, p < 0.001). Conclusion In functional MR, M-TEER reduced regurgitation degree more effectively, whereas AF ablation was associated with better survival, fewer hospitalizations, improved ventricular function, and greater symptom stability, supporting rhythm control as a preferred initial strategy in selected AF-related functional MR patientsKaplan–Meier of all-cause mortalityKaplan–Meier of time to first hospitalisation