COAPT vs MITRA-FR — TEER is about patient selection
COAPT showed that TEER added to optimized medical therapy reduced HF hospitalization and mortality in carefully selected secondary MR patients. MITRA-FR did not show significant clinical benefit in a different secondary MR population. The divergence is about patient selection — understanding it explains why TEER is reserved for COAPT-like profiles.
Two randomized trials tested TEER in secondary MR, but they did not enroll the same kind of patient. COAPT showed benefit in carefully selected patients. MITRA-FR did not show a significant clinical benefit in a broader population. If you want to understand why this tool says 'TEER may be reasonable in selected patients' rather than giving a blanket recommendation — the difference between these two trials is the key.
Key takeaway
COAPT and MITRA-FR enrolled different secondary MR populations. COAPT demonstrated benefit when TEER was added to maximally tolerated GDMT in carefully selected patients with significant secondary MR and LV size within defined limits. MITRA-FR did not show significant benefit in a population with more advanced LV remodeling relative to MR burden. The lesson is not that TEER works for all secondary MR — it is that TEER may help when the right patient is selected.
Key points
- COAPT enrolled symptomatic HFrEF patients with moderate-to-severe or severe secondary MR despite maximally tolerated GDMT — and showed reduced HF hospitalization and, at longer-term follow-up, lower mortality when TEER was added.
- MITRA-FR enrolled HFrEF patients with secondary MR using lower MR thresholds and did not show a significant reduction in death or HF hospitalization at 12 or 24 months.
- COAPT MR eligibility was based on integrated severity criteria, not EROA alone: enrollment included EROA ≥ 0.30 cm² or 3+ qualitative MR, and many patients had EROA ≥ 0.40 cm².
- COAPT-like features include LVEF 20–50%, LVESD ≤ 70 mm, PASP ≤ 70 mmHg, persistent symptoms despite optimized GDMT, severe secondary MR, and suitable anatomy.
- MITRA-FR included patients with larger ventricles relative to MR burden — a profile often interpreted as more proportionate secondary MR.
- This tool uses COAPT-like criteria as a gate, not as a guarantee of benefit. Final decision-making requires Heart Valve Team evaluation.
When to read this
Read this when the Intervention Navigator returns 'TEER may be reasonable in selected patients' and you want to understand the evidence behind that recommendation and what patient profile corresponds to the COAPT population.
What COAPT showed
The COAPT trial randomized 614 patients with HFrEF and moderate-to-severe or severe secondary MR who remained symptomatic despite maximally tolerated GDMT. Key eligibility included LVEF 20–50%, LVESD ≤ 70 mm, PASP ≤ 70 mmHg, and mitral anatomy suitable for MitraClip.
MR severity was assessed using integrated criteria, not EROA alone. Enrollment included patients with EROA ≥ 0.30 cm² or 3+ qualitative MR; many patients had severe secondary MR with EROA ≥ 0.40 cm².
The primary endpoint — HF hospitalization at 24 months — was 35.8% in the TEER group versus 67.9% in the medical therapy group. At longer-term follow-up, all-cause mortality was also lower in the TEER group. The key point is that this benefit was shown in a carefully and narrowly defined patient population.
What MITRA-FR showed
MITRA-FR randomized 304 patients with HFrEF and secondary MR to TEER plus medical therapy versus medical therapy alone. Eligibility used lower MR thresholds than COAPT, including EROA > 20 mm² or regurgitant volume > 30 mL/beat. GDMT optimization was required, but criteria were less stringent and the monitoring period shorter.
The primary endpoint — death or unplanned HF hospitalization at 12 months — was not significantly different between groups. At 24-month follow-up, results remained similar. MITRA-FR is a reminder that TEER does not benefit every patient with secondary MR.
Why the results diverged: patient selection
The difference between COAPT and MITRA-FR is best understood through patient selection. MITRA-FR included more patients with markedly enlarged ventricles relative to MR burden. In this setting, MR may reflect the degree of LV remodeling — a profile that has been described as proportionate secondary MR — and the prognosis is driven primarily by LV disease rather than the valve leak itself. Reducing MR may not be enough to meaningfully change the HF trajectory in this context.
COAPT, by contrast, limited LV size with LVESD ≤ 70 mm and selected patients with significant secondary MR relative to their degree of LV remodeling. This profile has been interpreted as closer to disproportionate secondary MR, where MR adds a hemodynamic burden beyond what the LV structural changes alone would produce. In this population, reducing MR appeared to add meaningful benefit beyond what optimized GDMT could achieve.
The proportionate versus disproportionate framework is a proposed explanatory model — not a formal classification system. It helps explain why two trials that both tested TEER in secondary MR reached different conclusions, but it is not a direct decision criterion in this platform.
How this affects clinical practice
ACC/AHA VHD 2020 gives a Class IIa recommendation for TEER in selected patients with chronic severe secondary MR who remain symptomatic despite optimized GDMT and meet COAPT-like clinical and anatomic criteria — LVEF 20–50%, LVESD ≤ 70 mm, PASP ≤ 70 mmHg, and suitable mitral anatomy. This is not a blanket recommendation for every patient with HFrEF and functional MR.
This tool uses COAPT-like criteria as a gate because clinical benefit was demonstrated in that selected population. Meeting the criteria does not guarantee benefit. Final decision-making requires Heart Valve Team evaluation.
TEER is not the same as curing secondary MR
TEER can reduce regurgitation and may improve symptoms, HF hospitalization, and survival in appropriately selected patients — but it does not treat the underlying cardiomyopathy. Patients remain at risk for progressive HF, and GDMT must continue after the procedure. TEER is a component of HF management, not a substitute for it.
Apply this in practice
Use the Secondary MR Intervention Navigator to evaluate TEER pathway eligibility.
Secondary MR Intervention Navigator