Background:
Right ventricular-pulmonary artery (RV-PA) coupling is an established marker of prognosis in mitral regurgitation (MR), but data on its change after transcatheter edge-to-edge mitral valve repair (M-TEER) in primary or atrial MR are limited.

Methods:
RV-PA coupling was evaluated in 190 patients undergoing M-TEER for primary or atrial MR before and one month after the procedure. RV-PA coupling was assessed using the ratio of tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP). The primary endpoint was the composite of death or hospitalization for heart failure during follow-up.

Results:
One month after M-TEER, RV-PA coupling improved in 78 patients (41.1%), driven by both improved RV systolic function (ΔTAPSE 2.2 ± 4.4 mm) and lower PASP (ΔPASP −14.7 ± 11.9 mmHg). Improvement in TAPSE/PASP was associated with less residual MR and better functional status after the procedure, but not with a lower risk of death or heart failure hospitalization during follow-up. In contrast, preserved RV-PA coupling at one month after M-TEER, defined as TAPSE/PASP >0.33 mm/mmHg, identified a subgroup at lower risk of the primary endpoint (hazard ratio 0.46 [95% confidence interval 0.26–0.81], p = 0.008).

Conclusion:
M-TEER is associated with improvement in RV-PA coupling in patients with primary or atrial MR. Persistent RV-PA uncoupling identifies a high-risk group for adverse events after the procedure. Future studies in dedicated aetiology-specific cohorts are required to establish the role of serial RV-PA coupling assessment in post-procedural risk stratification after M-TEER.