Mitral Regurgitation: Robotics or Transcatheter, Which Choice in 2025?

A new paradigm in the management of mitral regurgitation

Mitral regurgitation (MR) is now emerging as an endemic valvular pathology, driven by an aging population and increasing cardiac comorbidities. While the PREVUE VALVE study highlights a 8.2% prevalence of moderate valvular heart disease among 65-85 year olds, severe MR can affect up to 10% of patients suffering from chronic heart failure. Faced with this public health challenge, the ESC 2025 recommendations mark a conceptual breakthrough by precisely distinguishing the mechanisms of secondary MR (SMR): the ventricular form, linked to LV remodeling, and the atrial form, associated with atrial dilation and atrial fibrillation.

This literature review highlights current diagnostic and therapeutic advances to provide an integrated vision of management. The objective is to analyze the impact of multimodal imaging in the selection of candidates for new interventions, while comparing the efficacy of minimally invasive surgical approaches and transcatheter strategies (M-TEER, TMVR). The authors test the hypothesis that a multidisciplinary approach, based on this new pathophysiological classification, optimizes clinical outcomes for patients with increasingly complex anatomical profiles.

Review methodology

This publication constitutes a review of recent scientific literature and a synthesis of current clinical recommendations regarding mitral regurgitation (MR). The authors analyzed evidence-based data relating to diagnostic and therapeutic advances, notably integrating new pathophysiological concepts introduced by the ESC 2025 (European Society of Cardiology) guidelines.

The methodological analysis is based on the synthesis of the following fields:

• Etiological framework: Evaluation of the new classification distinguishing primary MR (intrinsic involvement) from secondary MR (SMR), subdivided into ventricular and atrial mechanisms.
• Prevalence data: Integration of figures from the PREVUE VALVE study involving a representative cohort of patients aged 65 to 85.
• Multimodal imaging: Analysis of techniques for evaluating valvular anatomy, ventricular remodeling, and procedural planning.
• Therapeutic arsenal: Comparison of minimally invasive surgical approaches (video-assisted thoracotomy, robotic assistance) and transcatheter interventions, including edge-to-edge repair (M-TEER with MitraClip or PASCAL systems), indirect annuloplasty (Carillon device) and transcatheter mitral valve replacement (TMVR).

The study examined recent literature to highlight individualized management strategies, based on the patient's specific anatomy and surgical risks assessed by the Heart Valve Team.

Epidemiological data and prevalence

The synthesis of clinical data, notably from the PREVUE VALVE study, confirms the extent of mitral regurgitation (MR) within the geriatric population. The authors report the following key figures:

• 65-85 age group: A weighted prevalence of 8.2% for moderate valvular heart disease.
• Moderate or severe MI: Estimated at 2% in this same cohort.
• Subjects over 65 years of age: MI affects more than 6% of this population.
• Chronic heart failure (HF): Up to 10% of patients present with severe MR.

New 2025 ESC classification and mechanisms

The review highlights a major evolution in the taxonomy of secondary MR (SMR), now segmented according to the predominant structural substrate. This distinction is crucial for the therapeutic choice:

Evolution of therapeutic strategies

Analysis of current practices shows a transition towards less invasive approaches, both surgical and percutaneous:

• Minimally invasive surgery: Video-assisted right thoracotomy and robotic surgery show favorable perioperative and clinical results compared to conventional sternotomy.
• Transcatheter interventions: Transcatheter Edge-to-Edge Repair (M-TEER) is establishing itself as the standard for patients at high surgical risk. For complex anatomies (severe annular calcifications, multi-segment prolapse), transcatheter mitral valve replacement (TMVR) is emerging as a viable alternative.
• Cardiac remodeling: The study specifies that in primary MR, eccentric hypertrophy is a consequence of overload, whereas in SMR, remodeling is both the cause and the consequence of the leak, creating a vicious cycle of cavitary dilation.

A new era in the management of mitral regurgitation

The synthesis of the data presented highlights a major paradigm shift, endorsed by the 2025 ESC recommendations. The distinction between ventricular and atrial secondary mitral regurgitation (sMR) redefines the therapeutic strategy: sMR is no longer solely a ventricular pathology, but can result from isolated atrial dilation with annular remodeling, often associated with atrial fibrillation. For the practitioner, this requires a more detailed morphological analysis via multimodal imaging to identify the driver of the regurgitation.

The study highlights the expansion of the therapeutic arsenal. While M-TEER (MitraClip, PASCAL) remains the transcatheter gold standard, the emergence of transcatheter mitral valve replacement (TMVR) offers a solution for complex anatomies, such as severe mitral annular calcifications (MAC), often excluded from conventional repairs. At the same time, the evolution towards minimally invasive surgery (right thoracotomy, robotics) demonstrates favorable perioperative results, confirming that the choice between surgery and percutaneous intervention no longer depends solely on surgical risk, but on precise anatomical suitability validated by the Heart Team.

The limitations of this review lie in the reliance on recent literature data for technologies still in the adoption phase (TMVR). Nevertheless, the established correlation between the mechanism (primary vs. secondary) and the cardiac remodeling response confirms the urgency of early intervention before the stage of irreversible ventricular dysfunction.

Data synthesis

This review reports a prevalence of mitral regurgitation (MR) exceeding 6% in those over 65 and reaching 10% in heart failure patients (PREVUE VALVE study). The analysis highlights the importance of the clinical distinction between ventricular and atrial secondary MR, introduced by the ESC 2025 guidelines, to optimize the use of M-TEER or minimally invasive surgery.

In concrete terms, for the practitioner:

• Diagnostic typology: Systematically distinguish secondary atrial MR (linked to annular dilation and AF) from ventricular MR, as their structural substrates require distinct therapeutic strategies.
• Interventional selection: Prioritize M-TEER (MitraClip or PASCAL) in patients at high surgical risk, reserving transcatheter replacement (TMVR) for complex anatomies ineligible for repair.
• Surgical modernization: Prioritize robotic surgery or video-assisted right thoracotomy to reduce perioperative morbidity and accelerate recovery compared to conventional sternotomy.

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