Mitral valve surgery after failed transcatheter intervention for mitral regurgitation: surgical techniques, challenges, and outcomes.

Objectives
This review article aims to examine the surgical approach to patients with failed mitral transcatheter edge-to-edge repair (M-TEER), focusing on operative challenges, decision-making, and contemporary outcome data. Technical considerations, including device removal and the management of complex mitral valve (MV) anatomy is discussed.Methods
We performed a comprehensive literature review and gathered the experience from high-volume centers in the surgical management of failed M-TEER.Results
MV surgery after failed M-TEER is a complex but increasingly necessary procedure as the use of M-TEER grows. It occurs in up to 6% of patients, with a median age of 70-76 years at the moment of failure and a median time to failure of < 6 months. MV surgery following M-TEER is associated with high mortality and morbidity, with a reported 30-day mortality ranging from 10-40% and 1-year survival below 60%. Functional device failure, structural device failure, MV disease progression and infective endocarditis are frequent mechanisms of M-TEER failure. Surgical MV repair is the preferred management strategy; however, due to the technical and anatomical complexity, MV replacement is performed much more frequently (MV repair rates <10%).Conclusions
MV surgery after failed M-TEER poses technical challenges due to the presence of altered anatomy, the need for concomitant procedures, and the patient's comorbidities. While surgical intervention carries increased risks, it remains the definitive treatment for failed M-TEER, offering durable relief from MR. Due to the technical complexities associated with these procedures, strong consideration should be given to transferring patients requiring MV surgery after failed M-TEER to high-volume MV centers.