Mitral Valve Surgery After Failed Transcatheter Intervention for Mitral Regurgitation: Techniques, Challenges, and Outcomes

This review article aims to examine the surgical approach to patients with failed mitral transcatheter edge-to-edge repair (M-TEER), focusing on operative challenges, decision-making, and contemporary outcome data. Technical considerations, including device removal and the management of complex mitral valve (MV) anatomy, are discussed. The authors performed a comprehensive literature review and gathered experience from high-volume centers in the surgical management of failed M-TEER.  The key messages from this review are: MV surgery after failed M-TEER is a complex but increasingly necessary procedure as the use of M-TEER grows. It occurs in up to six percent of patients, with a median age of 70–76 years at the time of failure and a median time to failure of less than six months. MV surgery following M-TEER is associated with high mortality and morbidity, with a reported 30-day mortality ranging from 10–40 percent and one-year survival below 60 percent. Functional device failure, structural device failure, MV disease progression, and infective endocarditis are frequent mechanisms of M-TEER failure. Surgical MV repair is the preferred management strategy; however, due to the technical and anatomical complexity, MV replacement is performed much more frequently (with MV repair rates below 10 percent).  The authors concluded that MV surgery after failed M-TEER poses technical challenges due to the presence of altered anatomy, the need for concomitant procedures, and the patient′s comorbidities. While surgical intervention carries increased risks, it remains the definitive treatment for failed M-TEER, offering durable relief from mitral regurgitation (MR). Due to the technical complexities associated with these procedures, strong consideration should be given to transferring patients requiring MV surgery after failed M-TEER to high-volume MV centers.