Clinical outcomes of catheter ablation vs transcatheter edge-to-edge repair as the initial intervention strategy in patients with atrial fibrillation and functional mitral regurgitation.
BACKGROUND: Atrial fibrillation (AF) and functional mitral regurgitation (FMR) frequently coexist and are linked through shared mechanisms of atrial and ventricular remodeling. Both catheter ablation and transcatheter edge-to-edge mitral valve repair (M-TEER) improve clinical status, yet the optimal sequence of these interventions remains unclear. OBJECTIVE: This study evaluated real-world outcomes in patients with AF and FMR, comparing catheter ablation and M-TEER as initial strategies, with a focus on mitral regurgitation (MR) severity, symptom stability, all-cause mortality, and all-cause cardiac hospitalizations. METHODS: We performed a single-center retrospective analysis of patients with AF and moderate to moderate-to-severe FMR. Patients were grouped according to the initial treatment strategy: AF ablation or M-TEER. Clinical and echocardiographic data were reviewed at baseline and follow-up. A 2-year retrospective follow-up was performed to evaluate changes in MR severity, symptom stability, all-cause mortality, and all-cause cardiac hospitalizations. RESULTS: A total of 281 patients were included (M-TEER, n = 129; AF ablation, n = 152). MR severity improved more frequently after M-TEER (P < .001). However, AF ablation was associated with better symptom stability (69% vs 44%; P < .001), markedly lower all-cause mortality (3% vs 14%; P = .002), less all-cause cardiac hospitalizations (P = .019), and significant improvement in left ventricular ejection fraction at follow-up (53% ± 11.1% vs 47% ± 13.9%; P < .001). CONCLUSION: M-TEER was associated with greater MR reduction, while AF ablation was associated with more favorable clinical outcomes. These findings likely reflect stage-dependent management rather than treatment superiority and require confirmation in prospective studies.