Transcatheter edge-to-edge repair for the management of secondary mitral regurgitation - CRT 2025 Beyond the Guidelines.

Secondary mitral regurgitation (SMR) remains a prevalent and challenging complication in patients with heart failure (HF), associated with poor prognosis despite optimal guideline-directed medical therapy (GDMT) and cardiac resynchronization therapy. Current American and European guidelines recommend GDMT as first-line therapy, with transcatheter edge-to-edge repair (TEER) reserved for severe symptomatic SMR patients who remain refractory. However, both guidelines preceded the reporting of pivotal randomized controlled trials (RESHAPE-HF2, MATTERHORN, and EFFORT) and emerging evidence in new clinical scenarios. At the 2025 Cardiovascular Research Technologies (CRT) conference, the session "Beyond the Guidelines" convened an expert panel to address existing gaps and evolving indications. Discussions highlighted unresolved questions regarding TEER in moderate SMR, asymptomatic patients, atrial functional MR, cardiogenic shock, and as a bridge in end-stage HF. Panel consensus emphasized the need for dedicated randomized trials in these subgroups and consideration of broader TEER use based on registry and observational data demonstrating procedural safety and clinical benefit. This review summarizes current evidence, knowledge gaps, and expert perspectives to inform future guideline development and optimize management of SMR across the spectrum of HF.