<div id="preview-section-abstract"> <div class="Abstracts u-font-serif text-s" id="abstracts"> <div class="abstract author" id="ab0005" lang="en"> <h2 id="hl0000397">Abstract</h2> <h2 id="hl0000399">Background</h2> <p id="hl0000400">Transcatheter mitral valve replacement (TMVR) faces anatomical challenges, currently limiting widespread adoption.</p> <h2 id="hl0000402">Objectives</h2> <p id="hl0000403">To describe the natural history and prognosis of patients ineligible for various TMVR devices.</p> <h2 id="hl0000405">Methods</h2> <p id="hl0000406">During a 4-year period (2019–2023) 3 TMVR devices (SAPIEN M3, Intrepid and Alta Valve) became available at a single institution (The Christ Hospital, Cincinnati, OH) in the setting of pivotal clinical trials or early feasibility study. Consenting patients who were deemed ineligible ≥1 of these trials were prospectively studied to capture anatomical reasons for ineligibility, cross-over to alternative mitral valve therapies (surgery or high-risk mitral transcatheter edge to edge repair [M-TEER]), and clinical events.</p> <h2 id="hl0000408">Results</h2> <p id="hl0000409">A total of 61 patients (out of 71 consenting patients or 85.9 %) were deemed ineligible for TMVR during the study period. The mean age was 79.2 ± 8.8 years, 65.6 % were female, with elevated surgical risk (median STS 4.3, IQR: 2.7–7.3). The 2 most common anatomical reasons for ineligibility were increased risk of left ventricular outflow tract obstruction (LVOTO) (n = 24, 39.3 %) and annular size (n = 29, 47.5 %).</p> <p id="hl0000410">During follow-up (median 277 [162–555] days) there were 7 deaths (11.5 %) and 12 (19.7 %) hospitalizations for heart failure. Management strategies included high-risk M-TEER in 11 patients (1 death [9.0 %], 0 HF hospitalizations [0 %]), surgery in 9 patients (0 deaths, 1 HF hospitalizations [11.1 %]), and medical management in 41 patients (6 deaths [14.6 %], 11 HF hospitalizations [26.8 %]) (p = 0.715 for mortality and p = 0.093 for HF hospitalizations). Residual MR ≥ moderate was 0 %, 50 %, and 100 % for surgery, M-TEER and medical treatment, respectively (p < 0.001).</p> <h2 id="hl0000412">Conclusions</h2> <p id="hl0000413">One third of patients deemed ineligible for TMVR are candidates for high-risk M-TEER or surgery with acceptable morbidity and mortality. Our results have practical implications for patient management.</p> </div> </div> </div>