A new dawn in mitral valve treatment: Shifting toward transcatheter techniques

Abstract Background Mitral regurgitation (MR) remains a highly prevalent and clinically impactful valvular disease, particularly in aging populations. While surgical repair or replacement is the cornerstone of treatment for primary MR (PMR), a considerable proportion of patients—especially those with secondary MR (SMR) and multiple comorbidities—are unsuitable for surgery. Over the past decade, transcatheter mitral interventions have expanded rapidly, providing new therapeutic opportunities for high-risk and inoperable patients. Objective This narrative review synthesizes the current landscape of transcatheter mitral therapies, emphasizing technological evolution, evidence maturity, patient selection principles, procedural approaches, and clinical outcomes. Content Transcatheter edge-to-edge repair (TEER) currently represents the only established transcatheter modality with guideline-supported indications and robust randomized evidence. In contrast, percutaneous annuloplasty—both indirect and direct—remains investigational, supported mainly by early-phase trials and limited cohort studies. Transcatheter mitral valve replacement (TMVR), including valve-in-valve (ViV), valve-in-ring (ViR), and valve-in-mitral annular calcification (ViMAC) procedures, shows substantial promise but is constrained by anatomical complexity, device-specific limitations, and the ongoing need for feasibility and safety data from dedicated registries. Across all modalities, optimal outcomes rely on rigorous patient selection guided by multimodality imaging and a multidisciplinary heart-team evaluation. Emerging percutaneous techniques, such as paravalvular leak closure, further complement the expanding spectrum of structural mitral therapies. Conclusion Transcatheter mitral interventions are reshaping the therapeutic paradigm of MR, extending effective treatment options to patients previously considered unsuitable for intervention. While TEER is now well established, annuloplasty and TMVR continue to evolve and require further evidence to define their long-term role. Continued clinical trials, real-world registries, and advancements in imaging and device technology are essential to clarify indications, address current evidence gaps, and optimize patient-centered outcomes.