Defining Procedural Success After Mitral Transcatheter Edge-to-Edge Repair. Is Anatomy Enough?

Mitral transcatheter edge-to-edge repair (M-TEER) has traditionally defined procedural success according to anatomical endpoints, principally residual mitral regurgitation (MR) and transmitral gradient. Although these measures remain fundamental, emerging evidence indicates that anatomical and physiological responses may not always be concordant. Studies evaluating intraprocedural left atrial pressure (LAP) have demonstrated that mismatch between residual MR and haemodynamic response is associated with adverse outcomes, while multiparametric haemodynamic assessment may provide additional prognostic information beyond anatomical assessment alone. Recent data from a large registry further suggest that intraprocedural mean LAP reduction is associated with improved outcomes in patients with degenerative MR, but not in those with functional MR, highlighting the potential importance of MR aetiology when interpreting haemodynamic response. However, direct LAP measurement is influenced by left atrial compliance, baseline filling pressures, volume status, anaesthetic depth, and vasoactive support, and a single intraprocedural pressure measurement should therefore not be considered an unequivocal marker of procedural adequacy. Importantly, current evidence does not establish a specific haemodynamic target or support physiology-guided procedural modification in routine practice. Rather, intraprocedural haemodynamic assessment may complement, rather than replace, anatomical evaluation by identifying patients in whom the physiological response to an anatomically successful intervention is suboptimal. Prospective randomized studies are needed to determine whether real-time haemodynamic guidance can improve procedural decision-making and clinical outcomes, and whether phenotype-specific physiological targets should be incorporated into the definition of procedural success. The future of M-TEER assessment may therefore lie not in anatomy versus physiology, but in integrating both.