Comparison of meta-analytical estimates between surgical repair and transcatheter edge-to-edge repair for atrial functional mitral regurgitation

Abstract OBJECTIVES Atrial functional mitral regurgitation lacks well-defined treatment guidelines. Medical therapy alone is insufficient, and either TEER (transcatheter edge to edge) or surgery is recommended. Short- and long-term comparative outcomes remain unclear. We aim to address this gap using available data. METHODS We performed a meta-analysis of studies examining the outcomes of surgery and/or transcatheter edge to edge. MEDLINE, EMBASE, and the Cochrane Library were assessed. The incidence rate of late severe MR was the primary outcome. A random model was performed. Leave-one-out, subgroup, and meta-regression analyses were conducted. RESULTS Thirty-two studies (1923 patients); 20 in surgery 1166 vs 12 in TEER 757) were selected. TEER patients were, on average, 10 years older, with twice the rate of NYHA III/IV symptoms and more than double the STS score. At a weighted mean follow-up of 3.2 years, compared to isolated transcatheter, surgery was associated with decreased incidence of late severe mitral regurgitation (2.53 vs 6.66 events per 100 person-years, P-interaction = 0.03), late all-cause mortality (3.00 vs 8.84, P-interaction = 0.024), late heart failure hospitalization (4.44 vs 17.03, P-interaction 0.01), and late NYHA III/IV (2.98 vs 22.47, P-interaction 0.01). However, significantly better long-term outcomes associated with surgery showed high heterogeneity. There were no differences in early all-cause mortality, early cardiac-specific mortality, late cardiac-specific mortality, postprocedural morbidities nor atrial diameter. On meta-regression, preprocedural heart failure (Beta = 0.0224, P 0.01) and coronary artery disease (Beta = 0.0294, P 0.00001) were linked to increased late severe mitral regurgitation. Older age, hypertension, mitral valve replacement, and associated aortic valve surgery were linked to increased late all-cause mortality. CONCLUSIONS Surgery and isolated transcatheter edge-to-edge repair showed comparable short-term outcomes, with surgery appearing more effective long-term; however, due to study limitations and heterogeneity, these findings are hypothesis-generating and require validation through prospective studies