Percutaneous mitral repair as treatment in HFrEF (MitraClip/TEER) imaging and assessment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nehal Eid, M.D.[2]

Imaging and Assessment

Scope

Preprocedural imaging determines whether mitral regurgitation (MR) is secondary, remains clinically important after optimized HFrEF therapy, is proportionate to ventricular remodeling, and is anatomically suitable for mitral transcatheter edge-to-edge repair (M-TEER). Intraprocedural guidance and postimplant surveillance are addressed in their respective microchapters.

Timing of definitive assessment

MR severity should be reassessed when the patient is euvolemic and after optimization of guideline-directed medical therapy (GDMT) and cardiac resynchronization therapy when indicated. Reverse remodeling may reduce secondary MR and eliminate the need for intervention; initiation of sacubitril/valsartan reduced potential eligibility for mitral repair by 44% in one study.[1][2]

Severity should be anchored to an awake transthoracic echocardiogram obtained under representative loading conditions. Sedation, general anesthesia, positive-pressure ventilation, and altered volume status during transesophageal echocardiography (TEE) may reduce secondary MR. A discrepancy between studies should prompt restoration of representative loading conditions or adjudication with another quantitative modality rather than automatic acceptance of the lower grade.[3]

Imaging sequence and modality selection

Modality Principal role Important limitations
Transthoracic echocardiography Establish MR mechanism and severity; measure left ventricular ejection fraction (LVEF), LV volumes, LV end-systolic dimension (LVESD), left atrial size, right ventricular (RV) function, tricuspid regurgitation (TR), and pulmonary artery systolic pressure (PASP) Secondary MR is load-dependent; two-dimensional proximal isovelocity surface area (PISA) may underestimate an elliptical or crescentic regurgitant orifice
Two- and three-dimensional transesophageal echocardiography Define leaflet anatomy, grasping-zone dimensions, jet location, tethering, calcification, baseline mitral-valve area and gradient, and intracardiac thrombus or vegetation Sedation may reduce MR severity; TEE should not replace representative awake TTE as the sole severity assessment
Cardiac magnetic resonance imaging Quantify LV volumes, regurgitant volume and fraction, myocardial scar, and cardiomyopathy etiology when echocardiographic measurements are discordant, technically limited, or affected by multiple or eccentric jets Availability, arrhythmia, device compatibility, and acquisition quality may limit use
Cardiac computed tomography Quantify mitral annular and leaflet calcification when echocardiography does not define its extent adequately; assess prognosis and alternative surgical or transcatheter options Not routinely required when echocardiography demonstrates uncomplicated, noncalcified M-TEER anatomy

[4][5]

In functional MR, CMR-derived regurgitant fraction and myocardial-scar burden provide prognostic information beyond conventional LV measurements and may refine assessment when echocardiographic severity and clinical status are discordant.[6]

Defining the secondary MR phenotype

  • Ventricular secondary MR: LV remodeling displaces the papillary muscles, increases leaflet tethering and tenting, and reduces closing force. Ischemic remodeling may produce asymmetric medial or posterior tethering and an eccentric jet; nonischemic dilated cardiomyopathy more often produces symmetric tethering and a central jet.[7]
  • Atrial secondary MR: left atrial and mitral-annular dilation, frequently associated with atrial fibrillation, produces leaflet-to-annulus mismatch despite relatively preserved LV geometry and systolic function.[8]
  • Primary or mixed MR: prolapse, flail leaflet, leaflet perforation, rheumatic restriction, endocarditis, or substantial degenerative calcification should not be mislabeled as ventricular secondary MR. Mixed disease requires explicit heart-team review because HFrEF trial criteria may not apply.

Atrial secondary MR subtypes

Three-dimensional TEE should distinguish two mechanistically different atrial-secondary-MR substrates:

  • Leaflet-to-annulus imbalance: total leaflet tissue is insufficient relative to annular enlargement. A leaflet-to-annulus index, calculated as total leaflet area divided by annular area, below approximately 1.1 identifies greater mismatch. Large left atrial volume index and a low leaflet-to-annulus index predict failure to reduce MR to ≤1+, whereas newer-generation M-TEER systems are associated with greater procedural success.[9]
  • Atriogenic leaflet tethering: atrial and posterior-annular displacement restricts the posterior leaflet and may produce an eccentric jet or apparent anterior-leaflet pseudoprolapse. This is a more challenging M-TEER substrate and is associated with greater procedural failure and residual MR.[10]

Evidence for M-TEER in atrial secondary MR is core-laboratory adjudicated but remains nonrandomized:

  • In the EXPANDed studies, 160 of 967 patients with secondary MR (17%) met atrial-secondary-MR criteria defined by atrial fibrillation, LVEF ≥45%, and at least one dilated left atrial parameter. Acute procedural success was 97.5%, MR was ≤1+ in 95.2% at 1 year, 1-year all-cause mortality was 9%, and the heart-failure hospitalization rate decreased by 56%.[11]
  • In a cohort of 118 atrial-secondary-MR patients, technical success was 94.1% and MR ≤1+ was achieved in 79.7%.[9]
  • In the Spanish Registry of MitraClip, 48 of 1,074 patients had atrial functional MR; procedural success was 91.7%, and 12-month survival free of heart-failure readmission and death was 74.9%.[12]
  • In MITRA-TUNE, 87 patients had technical success of 97% and residual MR ≤2+ in 89%. Intercommissural annular diameter ≥35 mm independently predicted death or heart-failure hospitalization (hazard ratio 4.16; 95% confidence interval 1.06–16.36), as did postprocedural MR ≥2+ (hazard ratio 5.40; 95% confidence interval 1.37–21.27).[13]

Atrial secondary MR occupies an intermediate prognostic position. Despite comparable procedural success, patients with atrial functional MR had higher 2-year rates of death or heart-failure hospitalization than patients with degenerative MR but lower rates than patients with ventricular functional MR.[14]

COAPT-derived ventricular-SMR criteria should not be transferred directly to isolated atrial secondary MR.

Quantifying secondary MR severity

No single echocardiographic measurement should determine candidacy. MR should be graded by integrating valve morphology, color Doppler, vena contracta, pulmonary-vein flow, continuous-wave Doppler density, effective regurgitant orifice area (EROA), regurgitant volume, regurgitant fraction, and chamber response.

Assessment Clinically relevant interpretation Principal limitation
EROA ACC/AHA severe-MR threshold: ≥0.40 cm². An outcome-anchored scheme derived from spline analysis of 5-year mortality uses baseline tiers of <0.20 cm², 0.20–0.29 cm², and ≥0.30 cm²; regurgitant fraction then reclassifies risk bidirectionally, with ≥50% moving risk upward and <50% moving risk downward. This is a prognostic framework, not a replacement guideline definition. Two-dimensional PISA assumes hemispheric convergence and may underestimate a crescentic secondary-MR orifice
Regurgitant volume ACC/AHA severe-MR threshold: ≥60 mL. A value ≥45 mL is outcome-associated but should be interpreted together with EROA and regurgitant fraction. Depends on accurate flow and annular measurements; may be lower in low-flow states
Regurgitant fraction ≥50% supports hemodynamically important MR and is the reclassification variable in the outcome-anchored EROA framework Requires reliable total and forward stroke-volume measurements
Vena contracta and three-dimensional vena-contracta area Useful when the orifice is noncircular or PISA is unreliable Multiple jets require separate characterization
Pulmonary-vein flow Systolic flow reversal supports severe MR and was incorporated into hierarchical trial screening Influenced by atrial fibrillation, left atrial pressure, and sampling location
Chamber response Record LV and left atrial volumes, LVESD, LVEF, pulmonary pressures, RV function, and TR Advanced LV disease may enlarge the ventricle independently of MR

[15][16]

When PISA geometry is unreliable, report the limitation rather than assigning false precision. Three-dimensional echocardiography, volumetric Doppler, or cardiac magnetic resonance should be used to adjudicate clinically important discordance.

RESHAPE-HF2 enrolled a less severe imaging phenotype than classical COAPT-like cohorts: mean EROA was approximately 0.25 cm², only 14% of participants had EROA >0.40 cm², and 23% had EROA <0.20 cm². This broadens the evidence base toward moderate-to-severe secondary MR but does not replace current guideline or device-label thresholds.[17]

MATTERHORN enrolled 210 patients with secondary MR who remained symptomatic despite GDMT and were judged by the local heart team to be eligible for either M-TEER or mitral surgery. Mean LVEF was 43.0±11.7%, median Society of Thoracic Surgeons predicted risk of mortality was 2.0% (interquartile range 1.1–3.7), and median EuroSCORE II was 3.0% (interquartile range 1.7–4.3). Median EROA was 0.22 cm² (interquartile range 0.17–0.28), mean regurgitant fraction was 57.0%, and MR grade ≥3+ was present in 96.0%. These imaging data further demonstrate enrollment of clinically important secondary MR below the conventional EROA ≥0.40 cm² threshold; comparative treatment outcomes are addressed in the procedural-therapy microchapter.[18]

Neither RESHAPE-HF2 nor MATTERHORN establishes an independent replacement for guideline severity thresholds.

Severity relative to ventricular remodeling

The report should include LVEF, LV end-diastolic volume, indexed LV volumes, and LVESD alongside MR measurements. A given EROA may represent a larger regurgitant fraction in a low-stroke-volume ventricle than in a larger ventricle with greater total stroke volume.

The proportionate-versus-disproportionate framework compares MR severity with LV remodeling and may help explain variation among clinical-trial populations. It remains a hypothesis-generating construct rather than a validated binary selection rule; no prospectively validated EROA-to-LV-volume or LV end-diastolic-volume cutoff should be used alone to deny treatment.[19]

Guideline- and label-linked imaging eligibility

Source Imaging-linked population Recommendation
ACC/AHA Symptomatic severe ventricular secondary MR despite optimized GDMT, including CRT when indicated; LVEF 20%–50%, LVESD ≤70 mm, PASP ≤70 mm Hg, and anatomy suitable for M-TEER Class IIa-B
ESC/EACTS Symptomatic severe secondary MR despite optimized GDMT; not eligible for surgery; imaging and clinical criteria suggest an increased likelihood of response Class IIa-B. Contemporary scientific statements summarize both American and European guidance as Class IIa for M-TEER in chronic severe secondary MR with LV systolic dysfunction, persistent NYHA class II–IV symptoms on optimal GDMT, and COAPT-like criteria.
ESC/EACTS advanced-HF pathway High procedural risk and surgical ineligibility without established response criteria, after consideration of left ventricular assist device or transplantation Class IIb-C
ACC/AHA atrial secondary MR Severe atrial secondary MR with preserved LVEF and persistent symptoms despite GDMT and treatment of atrial fibrillation and comorbidities: mitral-valve surgery may be considered Class IIb-B for surgery; no corresponding ESC/EACTS recommendation and no graded recommendation for M-TEER in either guideline

[20][21]

The inclusive values used in guideline summaries should not be conflated with strict regulatory, label-linked boundaries. The label-linked criteria use LVEF >20% and <50%, LVESD <70 mm, and PASP <70 mm Hg. COAPT excluded markedly elevated pulmonary pressures (>70 mm Hg) unless active vasodilator therapy reduced pulmonary vascular resistance to <3 Wood units, or to 3–4.5 Wood units with a pulmonary capillary wedge-pressure V wave less than twice the mean pulmonary capillary wedge pressure.[22][23]

Imaging eligibility is necessary but not sufficient for intervention. Symptoms, adequacy of GDMT, CRT status, coronary disease, competing valvular disease, frailty, expected survival, and advanced-HF options require multidisciplinary assessment.

Anatomic suitability on transesophageal echocardiography

TEE is the standard preprocedural modality for determining M-TEER anatomic suitability. Anatomic measurements are feasibility guides rather than stand-alone guideline indications. Contemporary devices may permit treatment outside older EVEREST- and COAPT-derived criteria, but increasing complexity raises the risk of residual MR, leaflet injury, or mitral stenosis.

Feature More favorable Challenging or unfavorable
Jet and target location Central A2–P2 target; dominant treatable jet Commissural or multiple widely separated jets; cleft, deep fold, or leaflet perforation
Grasping-zone tissue Mobile leaflet tissue with vertical coaptation length ≥2 mm; posterior leaflet length >10 mm Vertical coaptation length <2 mm or shorter posterior-leaflet tissue may be inadequate
Tethering Coaptation depth ≤11 mm Coaptation depth >11 mm reflects advanced tethering and may impair grasping
Flail anatomy Flail gap ≤10 mm and flail width ≤15 mm Flail gap >10 mm or flail width >15 mm
Calcification None or calcification outside the intended grasping zone Severe grasping-zone or leaflet calcification; extensive annular calcification with limited valve area
Baseline valve area and gradient Mitral-valve area >4.0 cm² and mean gradient ≤4 mm Hg Area 3.5–4.0 cm² is borderline; area <3.5 cm² or mean gradient >5 mm Hg indicates increased obstruction risk
Leaflet integrity No thrombus, mass, vegetation, or leaflet-body defect Intracardiac thrombus, vegetation, leaflet perforation, or rheumatic leaflet restriction

The 2020 ACC/AHA guideline identifies four COAPT-derived TEE exclusions as the anatomic screening standard: vertical coaptation length <2 mm, coaptation depth >11 mm, flail gap >10 mm, and flail width >15 mm. These criteria should be documented when present, including in mixed or potentially misclassified MR.[15][24]

TEE should also exclude left atrial or left atrial appendage thrombus, intracardiac mass, vegetation, and venous thrombus that would prevent safe access.

Mitral annular and leaflet calcification

Cardiac computed tomography can quantify mitral annular calcification (MAC), calcium volume, thickness, and leaflet involvement when echocardiography does not define the burden adequately. Moderate or severe MAC, defined by a CT score ≥4, was associated with lower functional procedural success than no significant MAC (56.1% versus 81.3%); greater calcium volume and MAC score independently predicted 2-year all-cause mortality irrespective of procedural success.[25]

In a separate cohort, calcium thickness >5 mm predicted 3-year all-cause mortality (odds ratio 2.38; 95% confidence interval 1.08–5.25), as did leaflet calcium involvement (odds ratio 6.71; 95% confidence interval 3.28–13.7).[26]

Right ventricle, pulmonary circulation, and tricuspid valve

Screening should document:

  • RV size and systolic function using multiple parameters, including tricuspid annular plane systolic excursion (TAPSE), tissue-Doppler systolic velocity, fractional area change, and RV free-wall strain when available.
  • TR mechanism and severity.
  • Estimated PASP and right atrial pressure, with acknowledgment of measurement quality.
  • RV–pulmonary artery coupling. A TAPSE/PASP ratio ≤0.33 mm/mm Hg is associated with approximately threefold higher mortality after mitral-valve interventions and identifies a high-risk phenotype; it is a prognostic marker rather than an absolute contraindication.[27][28]
  • Symptomatic right-sided heart failure and moderate or severe RV dysfunction.

COAPT formally excluded severe pulmonary hypertension, symptomatic right-sided heart failure with moderate or severe RV dysfunction, and tricuspid-valve disease requiring surgery. These findings define the boundary of the randomized evidence and should trigger explicit futility and advanced-HF assessment rather than routine proceeding.[29]

Adapted registry definitions of COAPT eligibility have operationalized acceptable right-heart status as TAPSE ≥15 mm and TR ≤2+. These are registry-derived screening values rather than original guideline thresholds or universal contraindications.[30]

When estimated pulmonary pressures are unreliable, discordant with the clinical findings, or near a decision boundary, right-heart catheterization should measure pulmonary pressures, pulmonary vascular resistance, cardiac output, and pulmonary capillary wedge pressure.

Integrated preprocedural checklist

  1. Confirm that MR has been reassessed under representative loading conditions after optimized GDMT and CRT when indicated.
  2. Distinguish ventricular, atrial, primary, and mixed MR.
  3. Report EROA, regurgitant volume, regurgitant fraction, vena contracta, pulmonary-vein flow, and important technical limitations.
  4. Document LVEF, indexed LV volumes, LVESD, left atrial size, and the relationship between MR severity and LV remodeling.
  5. State whether guideline-inclusive or strict label-linked ventricular and pulmonary thresholds are being applied.
  6. In atrial secondary MR, distinguish leaflet-to-annulus imbalance from atriogenic tethering and document the leaflet-to-annulus index and intercommissural annular diameter when three-dimensional measurements are available.
  7. Document the four COAPT-derived TEE exclusions: coaptation length <2 mm, coaptation depth >11 mm, flail gap >10 mm, and flail width >15 mm.
  8. Assess grasping-zone calcification, baseline mitral-valve area and gradient, and intracardiac thrombus or vegetation.
  9. Use cardiac computed tomography when clinically important annular or leaflet calcification is not adequately characterized by echocardiography.
  10. Assess RV function, TR, PASP, and RV–pulmonary artery coupling; identify formal COAPT right-heart exclusions.
  11. Present the integrated findings to the multidisciplinary heart team, including suitability for M-TEER, surgery, and advanced-HF therapy.

Limitations and unresolved issues

  • Loading dependence, noncircular regurgitant orifices, multiple jets, and nonholosystolic MR limit the reproducibility of individual echocardiographic measurements.
  • The Bartko risk tiers are prognostic and should not replace guideline severity definitions.
  • Proportionality is clinically informative but is not a validated exclusion criterion.
  • RESHAPE-HF2 and MATTERHORN include patients with EROA values below the conventional ≥0.40 cm² severe-MR threshold, but neither trial establishes a replacement quantitative threshold.
  • No guideline currently provides a graded recommendation for M-TEER in atrial secondary MR; available evidence is core-laboratory adjudicated but nonrandomized.
  • Atrial secondary MR carries an intermediate prognosis between degenerative and ventricular secondary MR despite comparable procedural success; anatomic feasibility should not be equated with expected clinical benefit.
  • COAPT-derived anatomic thresholds define the randomized evidence base but should not be treated as immutable technical exclusions for contemporary devices.
  • CT-defined mitral annular or leaflet calcification and impaired RV–pulmonary artery coupling identify higher-risk patients but are not absolute contraindications.

References

  1. ↑ Maddox TM, Januzzi JL, Allen LA; et al. (2024). "2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction". Journal of the American College of Cardiology. 83 (15): 1444–1488. doi:10.1016/j.jacc.2023.12.024.
  2. ↑ Bonow RO, O'Gara PT, Adams DH; et al. (2020). "2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation". Journal of the American College of Cardiology. 75 (17): 2236–2270. doi:10.1016/j.jacc.2020.02.005.
  3. ↑ O'Gara PT, Mack MJ (2020). "Secondary Mitral Regurgitation". The New England Journal of Medicine. 383 (15): 1458–1467. doi:10.1056/NEJMcp1903331.
  4. ↑ Bax JJ, Debonnaire P, Lancellotti P; et al. (2019). "Transcatheter Interventions for Mitral Regurgitation: Multimodality Imaging for Patient Selection and Procedural Guidance". JACC: Cardiovascular Imaging. 12 (10): 2029–2048. doi:10.1016/j.jcmg.2019.03.036.
  5. ↑ Uretsky S, Argulian E, Narula J, Wolff SD (2018). "Use of Cardiac Magnetic Resonance Imaging in Assessing Mitral Regurgitation: Current Evidence". Journal of the American College of Cardiology. 71 (5): 547–563. doi:10.1016/j.jacc.2017.12.009.
  6. ↑ Wang TKM, Kocyigit D, Choi H; et al. (2023). "Prognostic Power of Quantitative Assessment of Functional Mitral Regurgitation and Myocardial Scar Quantification by Cardiac Magnetic Resonance". Circulation: Cardiovascular Imaging. 16 (8): e015134. doi:10.1161/CIRCIMAGING.122.015134.
  7. ↑ Asgar AW, Mack MJ, Stone GW (2015). "Secondary Mitral Regurgitation in Heart Failure: Pathophysiology, Prognosis, and Therapeutic Considerations". Journal of the American College of Cardiology. 65 (12): 1231–1248. doi:10.1016/j.jacc.2015.02.009.
  8. ↑ Farhan S, Silbiger JJ, Halperin JL; et al. (2022). "Pathophysiology, Echocardiographic Diagnosis, and Treatment of Atrial Functional Mitral Regurgitation: JACC State-of-the-Art Review". Journal of the American College of Cardiology. 80 (24): 2314–2330. doi:10.1016/j.jacc.2022.09.046.
  9. ↑ 9.0 9.1 Tanaka T, Sugiura A, Öztürk C; et al. (2022). "Transcatheter Edge-to-Edge Repair for Atrial Secondary Mitral Regurgitation". JACC: Cardiovascular Interventions. 15 (17): 1731–1740. doi:10.1016/j.jcin.2022.06.005.
  10. ↑ Kagiyama N (2025). "Treatment Strategy of Atrial Functional Mitral Regurgitation: Consideration of the Mechanistic Subtypes". JACC: Cardiovascular Imaging. 18 (1): 30–32. doi:10.1016/j.jcmg.2024.07.027.
  11. ↑ Ricciardi MJ, Singh G, Rogers JH; et al. (2026). "Atrial Secondary Mitral Regurgitation Outcomes Following Mitral Transcatheter Edge-to-Edge Repair: Results From the EXPANDed Studies". Circulation: Cardiovascular Interventions: e015883. doi:10.1161/CIRCINTERVENTIONS.125.015883.
  12. ↑ Benito-González T, Carrasco-Chinchilla F, Estévez-Loureiro R; et al. (2021). "Clinical and Echocardiographic Outcomes of Transcatheter Mitral Valve Repair in Atrial Functional Mitral Regurgitation". International Journal of Cardiology. 345: 29–35. doi:10.1016/j.ijcard.2021.09.056.
  13. ↑ Popolo Rubbio A, Testa L, Grasso C; et al. (2022). "Transcatheter Edge-to-Edge Mitral Valve Repair in Atrial Functional Mitral Regurgitation: Insights From the Multi-Center MITRA-TUNE Registry". International Journal of Cardiology. 349: 39–45. doi:10.1016/j.ijcard.2021.11.027.
  14. ↑ Yoon SH, Makar M, Kar S; et al. (2022). "Outcomes After Transcatheter Edge-to-Edge Mitral Valve Repair According to Mitral Regurgitation Etiology and Cardiac Remodeling". JACC: Cardiovascular Interventions. 15 (17): 1711–1722. doi:10.1016/j.jcin.2022.07.004.
  15. ↑ 15.0 15.1 Otto CM, Nishimura RA, Bonow RO; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease". Journal of the American College of Cardiology. 77 (4): e25–e197. doi:10.1016/j.jacc.2020.11.018.
  16. ↑ Bartko PE, Arfsten H, Heitzinger G; et al. (2019). "A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation". Journal of the American College of Cardiology. 73 (20): 2506–2517. doi:10.1016/j.jacc.2019.02.075.
  17. ↑ Anker SD, Friede T, von Bardeleben RS; et al. (2024). "Transcatheter Valve Repair in Heart Failure with Moderate to Severe Mitral Regurgitation". The New England Journal of Medicine. 391 (19): 1799–1809. doi:10.1056/NEJMoa2314328.
  18. ↑ Baldus S, Doenst T, Pfister R; et al. (2024). "Transcatheter Repair versus Mitral-Valve Surgery for Secondary Mitral Regurgitation". The New England Journal of Medicine. 391 (19): 1787–1798. doi:10.1056/NEJMoa2408739. PMID 39216093 Check |pmid= value (help).
  19. ↑ Grayburn PA, Sannino A, Packer M (2019). "Proportionate and Disproportionate Functional Mitral Regurgitation: A New Conceptual Framework That Reconciles the Results of the MITRA-FR and COAPT Trials". JACC: Cardiovascular Imaging. 12 (2): 353–362. doi:10.1016/j.jcmg.2018.11.006.
  20. ↑ Coisne A, Lancellotti P, Habib G; et al. (2023). "ACC/AHA and ESC/EACTS Guidelines for the Management of Valvular Heart Diseases: JACC Guideline Comparison". Journal of the American College of Cardiology. 82 (8): 721–734. doi:10.1016/j.jacc.2023.05.061.
  21. ↑ Hahn RT, Lindenfeld J, Lim SD, Mack MJ, Burkhoff D (2024). "Structural Cardiac Interventions in Patients With Heart Failure: JACC Scientific Statement". Journal of the American College of Cardiology. 84 (9): 832–847. doi:10.1016/j.jacc.2024.05.061.
  22. ↑ Bonow RO, O'Gara PT, Adams DH; et al. (2020). "2019 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Mitral Valve Intervention". Journal of the American College of Cardiology. 76 (1): 96–117. doi:10.1016/j.jacc.2019.12.002.
  23. ↑ Brener MI, Grayburn P, Lindenfeld J; et al. (2021). "Right Ventricular-Pulmonary Arterial Coupling in Patients With Heart Failure Secondary Mitral Regurgitation: Analysis From the COAPT Trial". JACC: Cardiovascular Interventions. 14 (20): 2231–2242. doi:10.1016/j.jcin.2021.07.047.
  24. ↑ Beigel R, Wunderlich NC, Kar S, Siegel RJ (2014). "The Evolution of Percutaneous Mitral Valve Repair Therapy: Lessons Learned and Implications for Patient Selection". Journal of the American College of Cardiology. 64 (24): 2688–2700. doi:10.1016/j.jacc.2014.08.049.
  25. ↑ Tanaka T, Sugiura A, Schulz M; et al. (2024). "Cardiac Computed Tomography-Based Assessment of Mitral Annular Calcification in Patients Undergoing Mitral Transcatheter Edge-to-Edge Repair". Journal of Cardiovascular Computed Tomography. 18 (1): 26–32. doi:10.1016/j.jcct.2023.12.005.
  26. ↑ Nagasaka T, Patel V, Suruga K; et al. (2025). "Prognostic Significance of Mitral Annular Calcification Assessed by Computed Tomography for Transcatheter Edge-to-Edge Repair Outcomes". EuroIntervention. 21 (15): e847–e857. doi:10.4244/EIJ-D-24-01115.
  27. ↑ Rmilah AA, Ghaly R, Pfeiffer C; et al. (2025). "Prognostic Value of Baseline RV Dysfunction Using TAPSE and TAPSE to PASP Ratio in Patients Undergoing MitraClip: A Systematic Review and Meta-Analysis". The International Journal of Cardiovascular Imaging. 41 (5): 827–846. doi:10.1007/s10554-025-03354-5.
  28. ↑ Androshchuk V, Long E, Chehab O; et al. (2026). "The Prognostic Value of Right Ventricle-Pulmonary Artery Coupling in Valve Interventions: Systematic Review and Meta-Analysis". JACC: Cardiovascular Interventions. 19 (2): 174–188. doi:10.1016/j.jcin.2025.10.024.
  29. ↑ Hahn RT, Asch F, Weissman NJ; et al. (2020). "Impact of Tricuspid Regurgitation on Clinical Outcomes: The COAPT Trial". Journal of the American College of Cardiology. 76 (11): 1305–1314. doi:10.1016/j.jacc.2020.07.035.
  30. ↑ Koell B, Orban M, Weimann J; et al. (2021). "Outcomes Stratified by Adapted Inclusion Criteria After Mitral Edge-to-Edge Repair". Journal of the American College of Cardiology. 78 (24): 2408–2421. doi:10.1016/j.jacc.2021.10.011.
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