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........................... 12.3.2 Aortic regurgitation Severe aortic regurgitation can lead to progressive LV dilation with subsequent dysfunction, HF, and poor prognosis.

MT can improve HF symptoms in patients with severe aortic regurgitation. In particular, inhibitors of the RAAS can be useful.601 Beta-blockers should be cautiously used as they prolong diastole and may worsen aortic regurgitation. Aortic valve surgery is recommended in patients with severe aortic regurgitation and HF symptoms regardless of LVEF.592,602,603 In case of high or prohibitive surgical risk, TAVI has been used to treat also aortic regurgitation.604

12.3.3 Mitral regurgitation Primary (organic) mitral regurgitation Primary mitral regurgitation (MR) is caused by abnormalities of the valve apparatus and can cause HF. Surgery, preferably repair, is recommended in patients with severe primary MR and HF symptoms. If surgery is contraindicated

Management of secondary mitral regurgitation in patients with HFrEF

PCI (Class IIb) CABG and mitral

valve surgery

(Class IIa) Heart Team

(Class I)

Need for coronary revascularization OMT including CRT

if indicated

Y N

Y

High surgical risk

Persistence of HF symptomsa

and significant SMRb N

MT optimization and implant CRT if indicated

(Class I)

Y N

N Y

Consider surgery

if low-risk (Class IIb) Percutaneous EE mitral valve repair

(Class IIa) Consider percutaneous

EE mitral valve repair to improve symptoms or as BTT or to LVAD

(Class IIb) Maintain ongoing therapy.

Consider palliative care

and/or MCS or HT,

if possible

HeartTeam

(Class I) Follow-up

Echocardiographic and clinical criteria for outcome improvement after percutaneous EE mitral valve repairc

N Y

Figure 17 Management of secondary mitral regurgitation in patients with heart failure with reduced ejection fraction. BTT= bridge to transplantation; CABG= coronary artery bypass graft; CRT = cardiac resynchronization therapy; EE= edge-to-edge; EROA= effective regurgitant orifice area; HF= heart failure; LVAD= left ventricular assist device; LVEF= left ventricular ejection fraction; LVESD=left ventricular end-systolic diameter; MCS= mechanical circulatory support; MT =medical therapy; NYHA = New York Heart Association; OMT = optimal medical therapy; PCI= percutaneous coronary intervention; SMR= secondary mitral regurgitation; TR= tricuspid regurgitation. aNYHA class IIIV. bModerate-to-severe or severe (EROA >_30 mm2). cAll of the following criteria must be fulfilled: LVEF 2050%, LVESD <70 mm, systolic pulmonary pressure <70 mmHg, absence of moderate or severe right ventricular dysfunction or severe TR, absence of haemodynamic instability.612 Colour code for classes of recommendation: Green for Class of recommendation I; Yellow for Class of recommendation IIa; Orange for Class of recommendation IIb (see Table 1 for further details on classes of recommendation). Downloaded from academic.oup.com/eurheartj/article/42/36/3599/6358045 by guest on 07 October 2026