The role of transcatheter edge-to-edge repair in functional mitral regurgitation: key takeaways from the MATTERHORN and RESHAPE-HF2 trials.

Abstract

Functional mitral regurgitation (MR) is a common complication in heart failure (HF) and remains a major contributor to adverse outcomes despite advances in pharmacologic therapy. Guideline-directed medical therapy (GDMT) can lead to reverse remodeling and reduce MR severity in some patients, but many continue to experience symptomatic, moderate-to-severe MR. Transcatheter edge-to-edge repair (TEER) with the MitraClip® device has emerged as an important therapeutic option, particularly in patients who remain symptomatic despite optimized GDMT. Recent randomized trials-most notably RESHAPE-HF2 and MATTERHORN-have expanded the evidence base supporting TEER. RESHAPE-HF2 demonstrated that TEER significantly reduces heart failure hospitalizations and cardiovascular death in well-selected patients with moderate-to-severe functional MR, especially those with recent decompensation and favorable anatomy. MATTERHORN confirmed the noninferiority of TEER compared to surgery in high-risk patients, with a markedly better safety profile. These findings, alongside robust data on post-procedural GDMT intensification and functional improvement, support earlier integration of TEER into clinical practice. Collectively, the evidence suggests a paradigm shift: from reserving TEER as a last-resort therapy to incorporating it as an early intervention for appropriately selected patients with functional MR and persistent symptoms or incomplete reverse remodeling on optimal medical therapy.