Clinical outcomes of transcatheter edge-to-edge repair in patients with acute mitral regurgitation complicated by cardiogenic shock: a systematic review and meta-analysis

Abstract

Background: Acute mitral regurgitation (AMR) complicated by cardiogenic shock (CS) is a critical cardiovascular emergency associated with high morbidity and mortality. Surgical intervention is often not feasible due to the unstable clinical status of these patients. Transcatheter edge-to-edge repair (TEER) has emerged as a minimally invasive alternative, yet its safety and efficacy in this specific population remain uncertain. This study aimed to systematically evaluate and synthesize the evidence on the clinical outcomes of TEER in patients with AMR complicated by CS.

Methods: Databases including PubMed, Embase, and Web of Science were searched through March 4, 2025. Eligible studies included adult patients with AMR and CS undergoing TEER and reporting clinical outcomes. Data were synthesized using a random-effects model.

Results: The pooled in-hospital mortality rate following TEER was 17.8% (95% CI: 11.2-25.2%). One-month mortality was 7.9% (95% CI: 1.1-16.8%), six-month mortality was 21.0% (95% CI: 11.2-32.7%), and one-year mortality was 36.5% (95% CI: 34.9-38.2%). Among patients with degenerative MR, the one-year mortality was 7.9% (95% CI: 0.8-19.0%), while for functional MR it was 9.4% (95% CI: 1.3-21.5%). Postprocedural MR reduction to ≤ grade 2 was achieved in 86.2% of patients (95% CI: 70.7-97.3%). The intra-aortic balloon pump (IABP) application rate was 57.9% (95% CI: 24.2%-88.5%). Compared to usual care, TEER significantly reduced in-hospital mortality (OR = 0.64; 95% CI: 0.51-0.81; P < 0.01). However, no significant reduction was found in rehospitalization risk (OR = 0.65; 95% CI: 0.14-3.03; P = 0.59).

Conclusion: TEER appears to be a promising therapeutic option for patients with AMR complicated by CS. Compared to usual care, it is associated with significantly lower in-hospital mortality. However, high heterogeneity and low certainty of evidence highlight the need for further high-quality prospective studies to validate long-term outcomes and optimize patient selection.

Clinical trial number: Not applicable.

Keywords: Acute mitral regurgitation; Cardiogenic shock; Meta-analysis; MitraClip; Systematic review; Transcatheter edge-to-edge repair.

Fig. 1

Study selection process

Fig. 2

In-hospital mortality rate of TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 3

One-month mortality rate of TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 4

Six-month mortality rate of TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 5

One-year mortality rate of TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 6

One-year mortality rate due to degenerative MR of TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 7

One-year mortality rate due to functional MR of TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 8

Intra-aortic balloon pump application rate after TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 9

Intra-aortic balloon pump application rate after TEER in patients with CS: A: Forest plot, B: Sensitivity analysis, C: Galbraith plot

Fig. 10

Results of meta-analysis for in-hospital mortality of TEER vs. usual care in patients with CS. A: Forest plot B: Sensitivity analysis C: Galbraith plot D: Trim and fill analysis

Fig. 11

Results of meta-analysis for rehospitalization of TEER vs. usual care in patients with CS. A: Forest plot B: Sensitivity analysis C: Galbraith plot D: Trim and fill analysis