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Comparative Study
. 2026 Mar 13;47(11):1304-1314.
doi: 10.1093/eurheartj/ehaf511.

Transcatheter edge-to-edge repair vs medical therapy in atrial functional mitral regurgitation: a propensity score-based comparison from the OCEAN-Mitral and REVEAL-AFMR registries

Tomohiro Kaneko  1 , Nobuyuki Kagiyama  1 , Shinya Okazaki  1 , Masashi Amano  2 , Yukio Sato  3 , Yohei Ohno  4 , Masaru Obokata  5 , Kimi Sato  6 , Kojiro Morita  7 , Shunsuke Kubo  8 , Yuki Izumi  9 , Masahiko Asami  10 , Yusuke Enta  11 , Shinichi Shirai  12 , Masaki Izumo  3 , Shingo Mizuno  13 , Yusuke Watanabe  14 , Makoto Amaki  2 , Kazuhisa Kodama  15 , Hisao Otsuki  16 , Toru Naganuma  17 , Hiroki Bota  18 , Masahiro Yamawaki  19 , Hiroshi Ueno  20 , Gaku Nakazawa  21 , Daisuke Hachinohe  22 , Toshiaki Otsuka  23 , Mike Saji  9   24 , Masanori Yamamoto  25   26   27 , Kentaro Hayashida  28
Affiliations

Affiliations

  • 1 Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, Japan.
  • 2 Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan.
  • 3 Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan.
  • 4 Department of Cardiology, Tokai University School of Medicine, Isehara, Japan.
  • 5 Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.
  • 6 Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan.
  • 7 Department of Nursing Administration and Advanced Clinical Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
  • 8 Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan.
  • 9 Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan.
  • 10 Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan.
  • 11 Department of Cardiology, Sendai Kosei Hospital, Sendai, Japan.
  • 12 Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan.
  • 13 Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan.
  • 14 Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan.
  • 15 Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan.
  • 16 Department of Cardiology, Tokyo Woman's Medical University, Tokyo, Japan.
  • 17 Department of Cardiology, New Tokyo Hospital, Chiba, Japan.
  • 18 Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.
  • 19 Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan.
  • 20 Second Department of Internal Medicine, Toyama University Hospital, Toyama, Japan.
  • 21 Division of Cardiology, Department of Medicine, Kindai University Faculty of Medicine, Osaka, Japan.
  • 22 Division of Cardiology, Sapporo Cardio Vascular Clinic, Sapporo, Japan.
  • 23 Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan.
  • 24 Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan.
  • 25 Department of Cardiology, Toyohashi Heart Center, Toyohashi, Japan.
  • 26 Department of Cardiology, Nagoya Heart Center, Nagoya, Japan.
  • 27 Department of Cardiology, Gifu Heart Center, Gifu, Japan.
  • 28 Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
Comparative Study

Transcatheter edge-to-edge repair vs medical therapy in atrial functional mitral regurgitation: a propensity score-based comparison from the OCEAN-Mitral and REVEAL-AFMR registries

Tomohiro Kaneko et al. Eur Heart J. .
. 2026 Mar 13;47(11):1304-1314.
doi: 10.1093/eurheartj/ehaf511.

Authors

Tomohiro Kaneko  1 , Nobuyuki Kagiyama  1 , Shinya Okazaki  1 , Masashi Amano  2 , Yukio Sato  3 , Yohei Ohno  4 , Masaru Obokata  5 , Kimi Sato  6 , Kojiro Morita  7 , Shunsuke Kubo  8 , Yuki Izumi  9 , Masahiko Asami  10 , Yusuke Enta  11 , Shinichi Shirai  12 , Masaki Izumo  3 , Shingo Mizuno  13 , Yusuke Watanabe  14 , Makoto Amaki  2 , Kazuhisa Kodama  15 , Hisao Otsuki  16 , Toru Naganuma  17 , Hiroki Bota  18 , Masahiro Yamawaki  19 , Hiroshi Ueno  20 , Gaku Nakazawa  21 , Daisuke Hachinohe  22 , Toshiaki Otsuka  23 , Mike Saji  9   24 , Masanori Yamamoto  25   26   27 , Kentaro Hayashida  28

Affiliations

  • 1 Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, Japan.
  • 2 Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center, Suita, Japan.
  • 3 Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan.
  • 4 Department of Cardiology, Tokai University School of Medicine, Isehara, Japan.
  • 5 Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.
  • 6 Department of Cardiology, Institute of Medicine, University of Tsukuba, Tsukuba, Japan.
  • 7 Department of Nursing Administration and Advanced Clinical Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
  • 8 Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan.
  • 9 Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan.
  • 10 Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan.
  • 11 Department of Cardiology, Sendai Kosei Hospital, Sendai, Japan.
  • 12 Department of Cardiology, Kokura Memorial Hospital, Kitakyushu, Japan.
  • 13 Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan.
  • 14 Department of Cardiology, Teikyo University School of Medicine, Tokyo, Japan.
  • 15 Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Kumamoto, Japan.
  • 16 Department of Cardiology, Tokyo Woman's Medical University, Tokyo, Japan.
  • 17 Department of Cardiology, New Tokyo Hospital, Chiba, Japan.
  • 18 Department of Cardiology, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan.
  • 19 Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan.
  • 20 Second Department of Internal Medicine, Toyama University Hospital, Toyama, Japan.
  • 21 Division of Cardiology, Department of Medicine, Kindai University Faculty of Medicine, Osaka, Japan.
  • 22 Division of Cardiology, Sapporo Cardio Vascular Clinic, Sapporo, Japan.
  • 23 Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan.
  • 24 Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan.
  • 25 Department of Cardiology, Toyohashi Heart Center, Toyohashi, Japan.
  • 26 Department of Cardiology, Nagoya Heart Center, Nagoya, Japan.
  • 27 Department of Cardiology, Gifu Heart Center, Gifu, Japan.
  • 28 Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.

Erratum in

Abstract

Background and aims: Atrial functional mitral regurgitation (AFMR) commonly affects elderly and frail individuals. The prognostic impact of transcatheter edge-to-edge repair (TEER) for AFMR has not been investigated.

Methods: Patients with AFMR who underwent TEER were selected from the OCEAN-Mitral registry, and medically managed controls were selected from the REVEAL-AFMR registry, using an identical AFMR definition. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization. The secondary endpoint was all-cause mortality.

Results: A total of 1081 patients (mean age 80.1 ± 8.2 years, 60.5% female) with moderate or severe AFMR were included, of whom 441 underwent TEER and 640 remained on medical treatment. Overlap weighting based on the propensity score yielded well-balanced characteristics (n = 441 vs 640; all standardized mean differences <0.01), where TEER was associated with a lower incidence of the primary (hazard ratio [HR] 0.65, 95% confidence interval [CI] 0.43-0.99, P = .044) and secondary endpoints (HR 0.58, 95% CI 0.35-0.99, P = .044). In an exploratory subgroup analysis, favourable outcomes might be pronounced in patients with ≤mild residual AFMR after TEER, while event rates in those with ≥ moderate residual AFMR were comparable with the medication group. As sensitivity analyses, inverse probability of treatment weighting (n = 158 vs 173), propensity score matching (n = 104 vs 104), and multivariable Cox regression (n = 441 vs. 640) all confirmed favourable associations of TEER with both endpoints.

Conclusions: In real-world data, TEER for patients with moderate or severe AFMR were associated with a lower incidence of adverse events compared with medical treatment.

Keywords: Atrial functional mitral regurgitation; Heart failure; Mitral regurgitation; Transcatheter edge-to-edge repair.

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Figures

Structured Graphical Abstract

Structured Graphical Abstract

Comparison of patients with…

Structured Graphical Abstract

Comparison of patients with atrial functional mitral regurgitation treated with transcatheter edge-to-edge…

Structured Graphical Abstract
Comparison of patients with atrial functional mitral regurgitation treated with transcatheter edge-to-edge mitral valve repair vs medical therapy. CI, confidence interval; HFH, heart failure hospitalization; HR, hazard ratio; IPTW, inverse probability of treatment weighting; MR, mitral regurgitation; TEER, transcatheter edge-to-edge repair.
Figure 1

Figure 1

Adjusted Kaplan–Meier curves for both…

Figure 1

Adjusted Kaplan–Meier curves for both endpoints. Adjusted Kaplan–Meier curves using overlap weighting for…

Figure 1
Adjusted Kaplan–Meier curves for both endpoints. Adjusted Kaplan–Meier curves using overlap weighting for the composite endpoint of all-cause mortality and heart failure hospitalization (A, left) and all-cause death (A, right). Adjusted Kaplan-Meier curves using IPTW for the composite endpoint of all-cause mortality and heart failure hospitalization (B, left) and all-cause death (B, right). Adjusted Kaplan–Meier curves for 1:1 propensity score matching for the composite endpoint of all-cause mortality and heart failure hospitalization (C, left) and all-cause death (C, right). Event-free survival estimates with standard errors are shown for 3 years. The TEER-treated group (blue) consistently demonstrate better outcomes compared with the medically treated group (red). HFH, heart failure hospitalization; HR, hazard ratio; IPTW, inverse probability of treatment weighting; PS, propensity score; TEER, transcatheter edge-to-edge repair
Figure 2

Figure 2

Adjusted Kaplan–Meier curves stratified by…

Figure 2

Adjusted Kaplan–Meier curves stratified by residual MR severity at discharge. Adjusted Kaplan–Meier curves…

Figure 2
Adjusted Kaplan–Meier curves stratified by residual MR severity at discharge. Adjusted Kaplan–Meier curves stratified by residual MR severity at discharge in the TEER-treated group and the medically treated group for the composite endpoint of all-cause mortality and heart failure hospitalization (A) and all-cause death (B). Patients with mild or less residual MR (green) show significantly better outcomes compared with those with moderate or severe residual MR (blue) and the medically treated group (red). CI, confidence interval; HFH, heart failure hospitalization; HR, hazard ratio; MR, mitral regurgitation
Figure 3

Figure 3

Forest plot of subgroup analysis…

Figure 3

Forest plot of subgroup analysis for all-cause mortality and heart failure hospitalization. Subgroup…

Figure 3
Forest plot of subgroup analysis for all-cause mortality and heart failure hospitalization. Subgroup analyses showing HR with 95% CI for the composite endpoint of all-cause mortality and heart failure hospitalization in TEER-treated vs. medically treated groups. Subgroups include age, sex, MR severity, severity of tricuspid regurgitation, left atrial volume index, and left ventricular diameter. P-values for interaction are provided for each subgroup. LA, left atrium; LV, left ventricle; MR, mitral regurgitation; Paf, paroxysmal atrial fibrillation; TR, tricuspid regurgitation
See this image and copyright information in PMC

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