Transcatheter Mitral Valve Repair and Replacement. A Critical Review of Current Real-World Practice

OBJECTIVES: Transcatheter mitral valve interventions (TMVIs) provide less invasive alternatives for patients deemed ineligible for surgery. This manuscript reviews the evolving landscape of TMVI, limited to a comparative analysis of transcatheter edge-to-edge repair (TEER) and transcatheter mitral valve replacement (TMVR) in terms of safety and efficacy outcomes. METHODS: A comprehensive review of the existing literature was conducted, encompassing data from initial device trials to the most recent real-world studies, ranging from 2009 through 2025. A narrative synthesis was conducted to integrate findings and evaluate the current state of TMVI. RESULTS: Initially approved based on trials with stringent anatomical and clinical inclusion criteria, TEER has been increasingly applied to broader patient populations in real-world settings. Despite its expanded use, there remains a lack of randomized trial evidence for TEER in complex anatomies. TEER remains the preferred option for patients with suitable anatomy, given its well-established safety and efficacy, with over 200 000 patients treated. TMVR demonstrates promise in reducing mitral regurgitation (MR) but is associated with higher periprocedural risks, demands careful patient selection, and is supported by a more limited clinical experience, with just over 1400 patients treated. Emerging technological advancements are anticipated to reduce reliance on transapical access, aiming to improve procedural safety and outcomes. CONCLUSIONS: TEER and TMVR represent significant advancements in the management of MR. However, the field requires additional high-quality studies to clarify the efficacy and long-term outcomes of these interventions. Further technological developments in TMVR may enhance its safety profile and expand its applicability.