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Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 May 3, 2022 e947 CLINICAL STATEMENTS AND GUIDELINES

therapies, and consideration of surgical or transcatheter interventions accordingly to prevent worsening of HF and other adverse outcomes.1–10,12–20,22–35 2.	 GDMT, including RAAS inhibition, beta blockers, and biventricular pacing, improves MR and LV dimensions in patients with HFrEF and secondary MR, particularly MR that is proportionate to LV dilatation.1–5,12,13,17 In a small RCT, sacubitril-valsartan resulted in a significant reduction in effective regurgitant area and in regurgitant volume when compared with valsartan. The COAPT trial showed a mortality benefit with TEER in patients with severe secondary MR, LVEF between 20% and 50%, LV end-systolic diameter ≤70 mm, PA systolic pressure ≤70 mm Hg, and persistent symptoms (NYHA class II to IV) while on optimal GDMT,28 and these criteria apply when considering TEER. A cardiologist with expertise in the management of HF is integral to shared decision-making for valve intervention and should guide optimization of GDMT to ensure that medical options for HF and secondary MR have been effectively applied for an appropriate time period and exhausted before considering intervention.

Figure 10. Treatment Approach in Secondary Mitral Regurgitation. Colors correspond to Table 2. AF indicates atrial fibrillation; CABG, coronary artery bypass graft; ERO, effective regurgitant orifice; GDMT, guideline-directed medical therapy; HF, heart failure; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; MR, mitral regurgitation; MV, mitral valve; PASP, pulmonary artery systolic pressure; RF, regurgitant fraction; RVol, regurgitant volume; and Rx, medication. *Chordal-sparing MV replacement may be reasonable to choose over downsized annuloplasty repair. Adapted from Otto CM, et al.15 Copyright 2021 American College of Cardiology Foundation and American Heart Association, Inc.

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