When to Prefer MitraClip Over Cardiac Surgery

Abstract Severe mitral regurgitation (MR) is associated with an unfavourable prognosis, characterised by high mortality and reduced quality of life. Mitral surgery remains the gold standard for degenerative MR in patients with low operative risk, ensuring durability and improved survival; however, in elderly or frail patients, perioperative risk limits the applicability of surgical treatment. In this context, transcatheter edge-to-edge repair (TEER), predominantly with MitraClip™, has assumed an increasingly important role. The 2025 ESC/EACTS Guidelines recommend TEER in patients with severe secondary MR who remain symptomatic despite optimised medical therapy and cardiac resynchronisation, with evidence demonstrating reduced hospitalisations and improved quality of life. Randomised trials such as COAPT and RESHAPE-HF2 have consolidated these findings, while the MATTERHORN study has shown non-inferiority of TEER compared with surgery in terms of clinical efficacy, with a superior safety profile. In primary MR, ongoing studies (REPAIR-MR, MITRA-HR) are evaluating the effectiveness of TEER versus surgery in patients at moderate or high surgical risk. In summary, MitraClip currently represents the preferred therapeutic option in patients with high-risk secondary MR, while surgery remains indicated for repairable primary MR in low-risk surgical candidates.