Mid‐term outcomes (up to 5 years) of percutaneous edge‐to‐edge mitral repair in the real‐world according to regurgitation mechanism: A single‐center experience

Restoration of Life Expectancy After Transcatheter Edge-to-Edge Mitral Valve Repair

BACKGROUND

Survival data after mitral transcatheter edge-to-edge repair (TEER) are scarce, and its impact on predicted life expectancy is unknown.

OBJECTIVES

The aim of this study was to estimate the impact of TEER on postprocedural life expectancy among patients enrolled in the MitraSwiss registry through a relative survival (RS) analysis.

METHODS

Consecutive TEER patients 60 to 89 years of age enrolled between 2011 and 2018 (N = 1140) were evaluated. RS was defined as the ratio between post-TEER survival and expected survival in an age-, sex- and calendar period-matched group derived from the Swiss national 2011 to 2019 mortality tables. The primary aim was to assess 5-year survival and RS after TEER. The secondary aim was to assess RS according to the etiology of mitral regurgitation, age class and sustained procedural success over time.

RESULTS

Overall, 5-year survival after TEER was 59.3% (95% CI: 54.9%-63.4%), whereas RS reached 80.5% (95% CI: 74.6%-86.0%). RS was 91.1% (95% CI: 82.5%-98.6%) in primary mitral regurgitation (PMR) and 71.5% (95% CI: 63.0%-79.3%) in secondary mitral regurgitation (SMR). Patients 80 to 89 years of age (n = 579) showed high 5-year RS (93.0%; 95% CI: 83.3%-101.9%). In this group, restoration of predicted life expectancy was achieved in PMR with a 5-year RS of 100% (95% CI: 87.9%-110.7%), whereas sustained procedural success increased the RS rate to 90.6% (95% CI: 71.3%-107.3%) in SMR.

CONCLUSIONS

Mitral TEER in patients 80 to 89 years of age is able to restore predicted life expectancy in PMR, whereas in SMR with sustained procedural success, high RS estimates were observed. Our analysis suggests that successful, sustained mitral regurgitation reduction is key to survival improvement, particularly in patients 80 to 89 years of age.

Intraprocedural Residual Mitral Regurgitation and Survival After Transcatheter Edge-to-Edge Repair: Prospective German Multicenter Registry (MITRA-PRO)

BACKGROUND

Residual mitral regurgitation (MR) is thought to be an important predictor of long-term survival following transcatheter edge-to-edge repair (TEER). Intraprocedural MR assessment using transesophageal echocardiography could be limited by image quality, hemodynamics, and patient sedation. The MitraScore is a validated multimodal approach for intraprocedural MR assessment during TEER.

OBJECTIVES

This study aimed to assess the impact of residual MR using the MitraScore on 1-year mortality.

METHODS

Patients undergoing mitral TEER were eligible for inclusion in the prospective, multicenter MITRA-PRO registry (A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation). Patients with a MitraScore ≤3 were defined as patients with mild residual MR after mitral TEER, whereas a MitraScore ≥4 was considered as relevant residual MR. Mortality, rehospitalization, and major adverse events were assessed 1 year after TEER.

RESULTS

A MitraScore ≤3 was found in 1,059 patients (71.0%), whereas 432 patients revealed a MitraScore ≥4 (29.0%). One-year mortality was significantly lower in patients with nonrelevant residual MR (MitraScore ≤3 14.6% vs MitraScore≥4 22.1%). An almost linear relationship between intraprocedural MitraScore after TEER and mortality was observed. The combined clinical endpoint of mortality and rehospitalization within the 1-year follow-up was also significantly lower in the MitraScore ≤3 group (31.5%) than in the MitraScore ≥4 group (40.8%). A subgroup analysis confirmed the predictive value of the MitraScore in patients with primary, secondary, or mixed MR etiologies.

CONCLUSIONS

Residual MR assessed by intraprocedural MitraScore after TEER predicts 1-year mortality and rehospitalization. Therefore, the multimodal MitraScore improves MR assessment during mitral TEER and might improve patient survival.(A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation [MITRA-PRO]; DRKS00012288).

Late Infective Endocarditis After Transcatheter Mitral Valve Reconstruction (MitraClip): A Case Report and a Review of the Literature

Percutaneous transcatheter mitral valve reconstruction in edge to edge fashion is a well-established option in inoperable or high peri-operative risk patients with severe, symptomatic mitral valve regurgitation. MitraClip in combination with medical treatment improves survival and reduces hospitalization rates compared with optimal medical therapy alone in well selected patients. Clip-associated endocarditis is a rare complication with only few reported cases in the literature. We present a case of late infective endocarditis post Mitral Clip implantation and also review the literature regarding this new rare condition.

Thirty-day and one-year outcomes following transcatheter mitral valve edge-to-edge repair versus transapical mitral valve replacement in patients with left ventricular dysfunction

Background

A comparison of 30-day and 1-year clinical outcomes in patients with pre-existing left ventricular (LV) dysfunction undergoing transcatheter mitral valve edge-to-edge repair (TEER) or transcatheter transapical mitral valve replacement (TMVR) has not previously been reported.

Aims

We aimed to compare 30-day and 1-year rates of all-cause and cardiovascular mortality as well as rehospitalisation for heart failure (HFH).

Methods

All patients with severe (≥3+) symptomatic mitral regurgitation (MR) and an LV ejection fraction ≤50% who underwent TEER or TMVR over a 5-year period were evaluated.

Results

Ninety-six patients (50 TEER, age 80±9 years, 70% secondary MR and 46 TMVR, age 72±9 years, 91% secondary MR) were studied. Baseline demographic and transthoracic echocardiogram characteristics were well-matched, with the exception of age (TEER 80±9 vs TMVR 72±9; p=0.01). Successful device implantation occurred in 96% of TEER patients and 97.8% of TMVR patients. Ninety-two percent of TEER patients had ≤2+MR predischarge, whilst no TMVR patient had ≥1+MR (p<0.01). No significant difference in the combined endpoint of 30-day all-cause mortality or HFH was observed (p>0.05). At 1 year, freedom from all-cause mortality and HFH was 79.2% across the entire study population but was significantly higher in patients undergoing TEER (TEER: n=45 [90%] hazard ratio 11.26, 95% confidence interval [CI]: 10.59-11.93 vs TMVR: n=39 [67.4%] 95% CI: 10.09-11.33; p=0.008).

Conclusions

Despite comparable rates of successful device implantation, MR reduction, and 30-day all-cause mortality/HFH, TEER patients had lower all-cause mortality and HFH rates at 1 year.

Clinical outcomes and predictors in patients with previous cardiac surgery undergoing mitral valve transcatheter edge-to-edge repair

BACKGROUND

Mitral-valve transcatheter edge-to-edge repair (MV-TEER) is recommended in patients with severe functional mitral regurgitation (FMR) and in those with degenerative mitral regurgitation (DMR) not eligible to traditional surgery. Patients with a history of previous cardiac surgery are considered at high risk for surgical reintervention, but data are lacking regarding procedural and clinical outcomes.

OBJECTIVE

aim of this study was to assess the efficacy and clinical results of MV-TEER in patients with previous cardiac surgery enrolled in the "multicentre Italian Society of Interventional Cardiology registry of transcatheter treatment of mitral valve regurgitation" (GIOTTO).

METHODS

Patients with previous coronary artery bypass grafting (CABG), surgical aortic valve replacement (AVR), or mitral valve repair (MVR) were included. Those with multiple or combined previous cardiac surgeries were excluded. Clinical follow-up was performed at 30 days, 1 year, and 2 years. The primary endpoint was a composite of death or rehospitalization at 1- and 2-year follow-ups.

RESULTS

A total of 330 patients enrolled in the GIOTTO registry were considered (CABG 77.9%, AVR 14.2%, and MVR 7.9%). Most patients showed FMR (66.9%), moderate reduction of left ventricular (LV) ejection fraction, and signs of LV dilation. Procedural and device successes were 94.8% and 97%. At 1 and 2 years, the composite endpoint occurred are 29.1% and 52.4%, respectively. The composite outcome rates were similar across the three subgroups of previous cardiac surgery (p = 0.928) and between the FMR and DMR subgroups (p = 0.850) at 2 years. In a multivariate analysis, residual mitral regurgitation (rMR) ≥2+ was the main predictor of adverse events at 1 year (hazard ratio: 1.54 [95% confidence interval, CI: 1.00-2.38]; p = 0.050). This association was confirmed at 2 years of Kaplan-Meier analysis (p = 0.001).

CONCLUSIONS

MV-TEER is effective in these patients, regardless of the subtype of previous cardiac surgery and the MR etiology. An rMR ≥2+ is independently associated with adverse outcomes at 1-year follow-up.

Prognostic Value of Pulmonary Hypertension, Right Ventricular Function and Tricuspid Regurgitation on Mortality After Transcatheter Mitral Valve Repair: A Systematic Review and Meta-Analysis

BACKGROUND

Pulmonary hypertension (PH), right ventricular (RV) dysfunction, and tricuspid regurgitation (TR) are commonly present in patients with mitral regurgitation (MR) and known to impair prognosis. This systematic review and meta-analysis aimed to determine the prognostic value of PH, RV function, and TR on mortality after transcatheter mitral valve repair (TMVR).

METHODS

A systematic search was performed to identify studies investigating PH, RV function, or TR in patients who underwent TMVR. Studies were included for pooled analysis if hazard ratios (HR) for all-cause mortality were given.

RESULTS

A total of 8,672 patients from 21 selected studies were included (PH, 11 studies; RV function, nine studies; TR, 10 studies). Mean follow-up was 2.7±1.6 years. The HRs and 95% CIs for all-cause mortality of PH (dichotomised: HR 1.70, 95% CI 1.00-2.87; per 10 mmHg increase in systolic PAP: HR 1.17, 95% CI 1.07-1.29), RV function (dichotomised: HR 1.86, 95% CI 1.45-2.38; per 5 mm decrease in TAPSE: HR 1.18, 95% CI 0.97-1.43) and TR (HR 1.51, 95% CI 1.28-1.79) indicated a significant association.

CONCLUSION

Prognosis after TMVR is worse in patients with significant MR when concomitant PH, RV dysfunction, or TR are present. Careful assessment of these parameters should therefore precede clinical decision-making for TMVR. The current results encourage investigation into whether (1) intervention at an earlier stage of MR reduces incidence of PH, RV dysfunction, and TR; and (2) transcatheter treatment of concomitant TR can improve clinical outcome and prognosis for these patients.

Epidemiological Trends in Patients Undergoing Mitral Valve Transcatheter Edge-to-Edge Repair over the Last Decade: Functional vs. Structural Mitral Regurgitation

Objective: We aimed to investigate the demographic, clinical and hemodynamic characteristics of patients who underwent percutaneous mitral valve (MV) repair over the last decade, as well as to determine the potential changes in trends of these parameters among patients with structural and functional MR (SMR and FMR). Methodology: We analyzed all patients who underwent interventional MV repair in our institution between January 2010 and March 2021. Our study included both SMR and FMR patients. All data were obtained from a local registry. Results: Nine hundred and seventeen patients (357 SMR patients and 563 FMR patients) were involved in this study. We did not find significant differences in demographical, clinical and hemodynamic characteristics among SMR and FMR patients. Left ventricular remodeling and systolic dysfunction were more pronounced in FMR patients. Systemic vascular resistance was the only hemodynamic parameter that differed between SMR and FMR patients; it was higher in SMR group. An evaluation of the trend between the first and last five years of our experience revealed that the number of patients treated with this technique is constantly increasing, but that this is more pronounced in SMR patients. It was also found that the operative risk of SMR and FMR patients was significantly higher in the first five years. Additionally, our results showed change in medical therapy in MR patients over the last decade in terms of increased use of angiotensin II receptor blockers and the introduction of angiotensin receptor II blocker-neprilysin inhibitor. Conclusion: SMR and FMR patients who underwent interventional MV repair have similar clinical and hemodynamic characteristics. The percentage of SMR patients increased more significantly than FMR patients over the last five years.

Early symptomatic benefit indicates long-term prognosis after transcatheter mitral valve edge-to-edge repair in functional and degenerative etiology

BACKGROUND

Mitral regurgitation (MR) is common in patients with heart failure and constitutes an independent risk factor for adverse prognosis besides NYHA-class. The predictive value of dyspnea reduction after transcatheter mitral valve repair (TMVr) on outcome has not been investigated up to now.

METHODS AND RESULTS

We enrolled 627 consecutive patients (47.0% female, 57.4% functional MR; median follow-up 486 days[IQR 157/961]; survival status available in 96.8%; symptoms assessed in n = 556 at baseline / n = 406 at 1 month) treated with isolated percutaneous mitral valve edge-to-edge repair in our center from 06/2010-03/2018 (exclusion of combined forms of TMVr) in a monocentric retrospective analysis. Survival was 97.6% at discharge, 73.9% after 1, 54.5% after 3, 37.6% after 5 and 21.7% after 7-years. Before TMVr, NYHA-classes III/IV were found in 89.0%. Of these, 74.7% reported symptomatic relief (reduction in NYHA-class) one month after procedure (NYHA class recorded in 406 patients at 30 days). NYHA-classes III/IV were documented in 37.2% (p < 0.001) at 30 days and in 36.6% (p < 0.001) at 1 year without significant changes between the follow-ups. Dyspnea reduction was accompanied by significantly improved long-term survival (1 year, 89.1 vs 71.2%, p = 0.001, 2 years: 75.5 vs 58.7%, p = 0.039) and was identified as an independent predictor for lower mortality (1-year HR for increased mortality by missing symptomatic improvement 2.94 [95%CI 1.53-5.65], p = 0.001; long-term HR 1.95 [95%CI 1.29-2.94], p = 0.001) independently in both etiologies of MR.

CONCLUSION

TMVr by edge-to-edge therapy enables early and sustainable symptomatic improvement in nearly 75% of the symptomatic patients. The simple assessment of postinterventional changes in NYHA-class might serve as an independent predictor for mid- and long-term prognosis in both FMR and DMR.

Is the EuroSCORE II reliable in surgical mitral valve repair? A single-centre validation study

OBJECTIVES

The EuroSCORE II is widely used to predict 30-day mortality in patients undergoing open and transcatheter cardiac surgery. The aim of this study is to evaluate the discriminatory ability of the EuroSCORE II in predicting 30-day mortality in a large cohort of patients undergoing surgical mitral valve repair in a high-volume centre.

METHODS

A retrospective review of our institutional database was carried on to find all patients who underwent mitral valve repair in our department from January 2012 to December 2019. Discrimination of the EuroSCORE II was assessed using receiver operating characteristic curves. The maximum Youden's Index was employed to define the optimal cut-point. Calibration was assessed by generating calibration plot that visually compares the predicted mortality with the observed mortality. Calibration was also tested with the Hosmer-Lemeshow goodness-of-fit test. Finally, the accuracy of the models was tested calculating the Brier score.

RESULTS

A total of 2645 patients were identified, and the median EuroSCORE II was 1.3% (0.6-2.0%). In patients with degenerative mitral regurgitation (MR), the EuroSCORE II showed low discrimination (area under the curve 0.68), low accuracy (Brier score 0.27) and low calibration with overestimation of the 30-day mortality. In patients with secondary MR, the EuroSCORE II showed a good overall performance estimating the 30-day mortality with good discrimination (area under the curve 0.88), good accuracy (Brier score 0.003) and good calibration.

CONCLUSIONS

In patients with degenerative MR operated on in a high-volume centre with a high level of expertise in mitral valve repair, the EuroSCORE II significantly overestimates the 30-day mortality.

Impact of Residual Mitral Regurgitation on Survival After Transcatheter Edge-to-Edge Repair for Secondary Mitral Regurgitation

OBJECTIVES

The aim of this study was to assess the impact of residual mitral regurgitation (resMR) on mortality with respect to left ventricular dilatation (LV-Dil) or right ventricular dysfunction (RV-Dys) in patients with secondary mitral regurgitation (SMR) who underwent mitral valve transcatheter edge-to-edge repair (TEER).

BACKGROUND

The presence of LV-Dil and RV-Dys correlates with advanced stages of heart failure in SMR patients, which may impact the outcome after TEER.

METHODS

SMR patients in a European multicenter registry were evaluated. Investigated outcomes were 2-year all-cause mortality and improvement in New York Heart Association functional class with respect to MR reduction, LV-Dil (defined as LV end-diastolic volume ≥159 ml), and RV-Dys (defined as tricuspid annular plane systolic excursion-to-systolic pulmonary artery pressure ratio of <0.274 mm/mm Hg).

RESULTS

Among 809 included patients, resMR ≤1+ was achieved in 546 (67%) patients. Overall estimated 2-year mortality rate was 32%. Post-procedural resMR was significantly associated with mortality (p = 0.031). Although the improvement in New York Heart Association functional class persisted regardless of either LV-Dil or RV-Dys, the beneficial treatment effect of resMR ≤1+ on 2-year mortality was observed only in patients without LV-Dil and RV-Dys (hazard ratio: 1.75; 95% confidence interval: 1.03 to 3.00).

CONCLUSIONS

Achieving optimal MR reduction by TEER is associated with improved survival in SMR patients, especially if the progress in heart failure is not too advanced. In SMR patients with advanced stages of heart failure, as evidenced by LV-Dil or RV-Dys, the treatment effect of TEER on symptomatic improvement is maintained, but the survival benefit appears to be reduced.

Relationship Between Residual Mitral Regurgitation and Clinical and Quality-of-Life Outcomes After Transcatheter and Medical Treatments in Heart Failure: COAPT Trial

BACKGROUND

In the randomized COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation), among 614 patients with heart failure with 3+ or 4+ secondary mitral regurgitation (MR), transcatheter mitral valve repair (TMVr) with the MitraClip reduced MR, heart failure hospitalizations, and mortality and improved quality of life compared with guideline-directed medical therapy (GDMT) alone. We aimed to examine the prognostic relationship between MR reduction and outcomes after TMVr and GDMT alone.

METHODS

Outcomes in COAPT between 30 days and 2 years were examined on the basis of the severity of residual MR at 30 days.

RESULTS

TMVr-treated patients had less severe residual MR at 30 days than GDMT-treated patients (0/1+, 2+, and 3+/4+: 72.9%, 19.9%, and 7.2% versus 8.2%, 26.1%, and 65.8%, respectively [P<0.0001]). The rate of composite death or heart failure hospitalizations between 30 days and 2 years was lower in patients with 30-day residual MR of 0/1+ and 2+ compared with patients with 30-day residual MR of 3+/4+ (37.7% versus 49.5% versus 72.2%, respectively [P<0.0001]). This relationship was consistent in the TMVr and GDMT arms (P_interaction=0.92). The improvement in Kansas City Cardiomyopathy Questionnaire score from baseline to 30 days was maintained between 30 days and 2 years in patients with 30-day MR ≤2+ but deteriorated in those with 30-day MR 3+/4+ (-0.3±1.7 versus -9.4±4.6 [P=0.0008]) consistently in both groups (P_interaction=0.95).

CONCLUSIONS

In the COAPT trial, reduced MR at 30 days was associated with greater freedom from death or heart failure hospitalizations and improved quality of life through 2-year follow-up whether the MR reduction was achieved by TMVr or GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

COAPT-Like Profile Predicts Long-Term Outcomes in Patients With Secondary Mitral Regurgitation Undergoing MitraClip Implantation

OBJECTIVES

The aim of this study was to evaluate whether fulfilling COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) criteria identifies patients with better outcomes after MitraClip treatment for secondary mitral regurgitation (SMR).

BACKGROUND

To date, COAPT is the only trial showing a prognostic benefit of MitraClip implantation compared with conservative management.

METHODS

Three hundred four patients with SMR undergoing MitraClip placement in addition to optimal medical therapy at 3 European centers were analyzed. A COAPT-like profile was defined as absence of all the following criteria: severe left ventricular impairment, moderate to severe right ventricular dysfunction, severe tricuspid regurgitation, severe pulmonary hypertension, and hemodynamic instability. Freedom from all-cause death and from a composite endpoint (cardiovascular death and heart failure hospitalization) were evaluated at 2- and 5-year follow-up.

RESULTS

A COAPT-like profile was observed in 65% of the population. Compared with non-COAPT-like patients, those fulfilling COAPT criteria had greater survival free from all-cause death and from the composite endpoint at both 2 year (75% vs. 55% and 67% vs. 47%; p < 0.001 for both) and 5-year (49% vs. 25% and 40% vs. 19%; p < 0.001 for both) follow-up. Among the non-COAPT-like patients, similar outcomes were observed in those fulfilling 1 or ≥1 criterion. Left ventricular impairment had a late impact on outcomes, while right ventricular impairment, pulmonary hypertension, and hemodynamic instability had early effects. COAPT-like profile was an independent predictor of long-term outcomes, as well as administration of neurohormonal antagonists, European System for Cardiac Operative Risk Evaluation II score, and previous heart failure hospitalization.

CONCLUSIONS

A COAPT-like profile, including specific echocardiographic and clinical criteria, identifies patients with SMR who have a better prognosis after MitraClip implantation.

Predictors of outcomes in patients with mitral regurgitation undergoing percutaneous valve repair

Percutaneous mitral valve repair has been increasingly performed worldwide after approval. We sought to investigate predictors of clinical outcome in patients with mitral regurgitation undergoing percutaneous valve repair. The MITRA-UMG study, a single-centre registry, retrospectively collected consecutive patients with symptomatic moderate-to-severe or severe MR undergoing MitraClip therapy. The primary endpoint was the composite of cardiovascular death or rehospitalization for heart failure. Between March 2012 and July 2018, a total of 150 consecutive patients admitted to our institution were included. Procedural success was obtained in 95.3% of patients. The composite primary endpoint of cardiovascular death or rehospitalization for HF was met in 55 patients (37.9%) with cumulative incidences of 7.6%, 26.2%, at 30 days and 1-year, respectively. In the Cox multivariate model, NYHA functional class and left ventricular end-diastolic volume index (LVEDVi), independently increased the risk of the primary endpoint at long-term follow-up. At Kaplan–Meier analysis, a LVEDVi > 92 ml/m² was associated with an increased incidence of the primary endpoint. In this study, patients presenting with dilated ventricles (LVEDVi > 92 ml/m²) and advanced heart failure symptoms (NYHA IV) at baseline carried the worst prognosis after percutaneous mitral valve repair.

Relationship volume-outcome for transcatheter mitral-valve repair: When technique matters

Edge-to-edge mitral repairment is a valid alternative in patient at high surgical risk. It is important to differentiate outcomes for functional and degenerative mitral regurgitation. The need of joint efforts to ensure a valid therapeutic pathway for these patients.

Single-center five-year outcomes after interventional edge-to-edge repair of the mitral valve

BACKGROUND

The MitraClip procedure was established as a therapeutic alternative to mitral valve surgery for symptomatic patients with severe mitral regurgitation (MR) at prohibitive surgical risk. In this study, the aim was to evaluate 5-year outcomes after MitraClip.

METHODS

Consecutive patients undergoing the MitraClip system were prospectively included. All patients underwent clinical follow-up and transthoracic echocardiography.

RESULTS

Two hundred sixty-five patients (age: 81.4 ± 8.1 years, 46.7% female, logistic EuroSCORE: 19.7 ± 16.7%) with symptomatic MR (60.5% secondary MR [sMR]). Although high procedural success of 91.3% was found, patients with primary MR (pMR) had a higher rate of procedural failure (sMR: 3.1%, pMR: 8.6%; p = 0.04). Five years after the MitraClip procedure, the majority of patients presented with reduced symptoms and improved functional capacity (functional NYHA class: p = 0.0001; 6 minutes walking test: p = 0.04). Sustained MR reduction (≤ grade 2) was found in 74% of patients, and right ventricular (RV) function was significantly increased (p = 0.03). Systolic pulmonary artery pressure (sPAP) was significantly reduced during follow-up only in sMR patients (p = 0.05, p = 0.3). Despite a pronounced clinical and echocardiographical amelioration and low interventional failure, 5-year mortality was significantly higher in patients with sMR (p = 0.05). The baseline level of creatinine (HR: 0.695), sPAP (HR: 0.96) and mean mitral valve gradient (MVG) (HR: 0.82) were found to be independent predictors for poor functional outcome and mortality.

CONCLUSIONS

Transcatheter mitral valve repair with the MitraClip system showed low complication rates and sustained MR reduction with improved RV function and sPAP 5 years after the procedure was found in all patients, predominantly in patients with sMR. Despite pronounced functional amelioration with low procedure failure, sMR patients had higher 5-year mortality and worse outcomes. Baseline creatinine, MVG, and sPAP were found to be independent predictors of poor functional outcomes and 5-year mortality.