Characterization of Patients Unsuited for Transcatheter Mitral Valve Interventions

<b>Background/Objectives</b>: The objective of this study was to characterize echocardiographic characteristics comparing patients accepted or deemed unsuitable for transcatheter mitral valve interventions. <b>Methods</b>: We performed a retrospective analysis of 293 patients with severe mitral regurgitation evaluated for mitral transcatheter edge-to-edge repair (M-TEER) or transcatheter mitral valve replacement (TMVR), if patients were primarily identified as unsuitable candidates for M-TEER, at our institution between 2018 and 2023. All patients underwent transthoracic and transesophageal echocardiography, and mitral valve quantification (MVQ) analysis was performed. Feasibility was determined by an interdisciplinary Heart Team based on quantitative data and semi-quantitative echocardiographic parameters, including mean pressure gradient, regurgitation volumes, and morphological aspects alongside clinical assessment. Patient characteristics were evaluated using clinical records and echocardiographic data. <b>Results</b>: We screened 195 patients for M-TEER, 168 of which were accepted for the procedure. M-TEER-rejected patients presented with higher regurgitation volumes and higher transmitral pressure gradients than those accepted to undergo M-TEER. We then screened 104 patients for TMVR, and 27 were approved for the procedure. Patients rejected for TMVR presented with lower tenting volume, area, and height and had smaller ventricular diameters. Further, mitral valve area appears to be an important parameter in determining MR treatment strategy. <b>Conclusions:</b> The majority of MR patients screened for transcatheter intervention were suitable for M-TEER. However, elevated MPG and more pronounced billowing were the main factors associated with M-TEER exclusion. Conversely, the only morphological parameter associated with TMVR refusal was small left ventricular size. Importantly, the multimorbidity of patients and level of critical illness did not prohibit TMVR.