When to consider mitral valve surgery in dogs: a comparative review of open mitral valve repair and transcatheter edge-to-edge repair with a proposed selection framework

Myxomatous mitral valve disease (MMVD) is the most common acquired cardiac disease in dogs, and progression to congestive heart failure (CHF) and cardiac death remains common despite optimal medical management. Two surgical interventions are now clinically available for dogs with advanced MMVD: open mitral valve repair (OMVR) under cardiopulmonary bypass and transcatheter edge-to-edge repair (TEER) using the canine V-Clamp device. This narrative review synthesizes the contemporary literature on both techniques and proposes a framework to guide patient selection. OMVR has more than a decade of clinical experience and a published outcome base of more than 1,000 dogs, with surgical survival rates exceeding 99% across all clinical stages and long-term mortality risk modulated by age, body weight, breed, and pulmonary vascular status. V-Clamp TEER has emerged since 2020 with multiple published clinical cohorts demonstrating high acute procedural feasibility (96–97% in the largest series) and, most recently, sustained one-year hemodynamic and remodeling improvements with two-year all-cause survival of 67% at the leading reporting center; outcomes vary across centers, reflecting the interacting influence of patient selection, anatomic eligibility, and operator learning curve. Because the two techniques differ in evidence maturity and in the outcome metrics reported, direct numerical comparison between them requires caution. OMVR achieves more complete mitral regurgitation (MR) reduction, while V-Clamp produces a less invasive double-orifice repair with intermediate hemodynamic effect that may partially regress in the presence of significant residual MR. A proposed selection framework integrates ACVIM stage, mitral valve anatomy, body size, comorbidity burden, and center experience to guide decisions among OMVR, V-Clamp, and continued medical management. Honest owner counseling that includes center-specific experience and the limits of each option remains a clinical priority as the field evolves.