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............................................................................................................................................................................. common. The impact of coronary revascularization in patients with silent CAD accompanying aortic stenosis is unclear and further studies are warranted in this context (section 3). Both simultaneous SAVR and CABG, and SAVR late after CABG, carry a higher procedural risk than isolated SAVR. Nevertheless, retrospective data indicate that patients with moderate aortic stenosis, in whom CABG is indicated, benefit from concomitant SAVR. Patients aged <70 years with mean gradient progression >_5 mmHg/year benefit from SAVR at the time of CABG once baseline peak gradient exceeds 30 mmHg.258 Decisions for individual patients should take into account haemodynamic data, rate of progression, extent of leaflet calcification, life expectancy, and associated comorbidities, as well as the individual risk of concomitant SAVR or deferred TAVI.244

Percutaneous coronary intervention (PCI) and TAVI may be undertaken as combined or staged procedures according to the clinical situation, pattern of CAD, and extent of myocardium at risk.259 In the SURTAVI trial, there was no significant difference in the primary endpoint (all-cause mortality or stroke at 2-year follow-up) in intermediate-risk patients with severe aortic stenosis and noncomplex CAD (SYNTAX score <22) undergoing either TAVI and PCI or SAVR and CABG [16.0% (95% CI, 11.122.9) vs. 14% (95% CI, 9.221.1); P = 0.62].260 Assessing the clinical value of systematic PCI in TAVI patients with significant associated CAD is the objective of ongoing RCTs. Patients with severe symptomatic aortic stenosis and diffuse CAD unsuitable for revascularization should receive optimal medical therapy and undergo SAVR or TAVI according to individual characteristics. Severity of mitral regurgitation accompanying severe aortic stenosis may be overestimated as a result of elevated LV pressures and careful quantification is required. In patients with severe primary mitral regurgitation (PMR), mitral valve surgery is required at the time of SAVR. In patients with severe SMR, surgery may also be considered in the presence of significant annular dilatation and marked LV enlargement. In high-risk or inoperable patients with severe aortic stenosis and severe mitral regurgitation, combined (or more often sequential) TAVI and TEER may be feasible, but there is insufficient experience to allow robust recommendations.261263 In patients with severe PMR, TEER should be considered early if the patient remains symptomatic and mitral regurgitation is still severe after TAVI. In patients with severe SMR, TAVI should be followed by careful clinical and echocardiographic reassessment to determine whether further mitral intervention is required.264 Section 4 provides recommendations for the management of aneurysm/dilatation of the ascending aorta accompanying aortic stenosis. Assessment and management of congenital aortic stenosis is addressed in ESC Guidelines on adult congenital heart disease.265

6 Mitral regurgitation

Mitral regurgitation is the second-most frequent VHD in Europe.1,3 The underlying mechanism (primary or secondary) determines the therapeutic approach.

6.1 Primary mitral regurgitation

Primary lesion of one or more components of the mitral valve apparatus characterizes PMR. Degenerative aetiology (fibroelastic deficiency and Barlow disease) is most frequent in Western countries.1,2,266 In low-income countries, rheumatic aetiology is the most frequent cause of mitral regurgitation.267 Endocarditis can cause PMR and is addressed in the corresponding ESC Guidelines.4

6.1.1 Evaluation Echocardiography is the first choice of imaging technique to grade PMR (Table 7). An integrative approach including qualitative, semiquantitative, and quantitative measures of mitral regurgitation (besides quantification of LV and LA dimensions) is recommended.24,268 Routinely measured effective regurgitant orifice area (EROA) is strongly associated with all-cause mortality, and compared with the general population an excess mortality appears for an EROA >_20 mm2 and steadily increases beyond 40 mm2.269 Evaluation of the specific lesion leading to mitral regurgitation has prognostic implications266,270 and is fundamental to determine the feasibility of surgical and transcatheter valve repair271273 (Supplementary Figure 1). Threedimensional TOE provides an ‘en face’ view of the mitral leaflets resembling the surgical inspection of the valve, thereby facilitating Heart Team discussion.24,268 In addition, 3D echocardiography has shown better agreement with CMR in quantifying the regurgitant volume than 2D echocardiography, particularly in eccentric, multiple and late-systolic regurgitant jets.274277 When various echocardiographic parameters used to grade mitral regurgitation are inconsistent, CMR is a valid alternative to quantify the regurgitant volume and is the reference standard to quantify LV and LA volumes.278 In addition, quantification of mitral regurgitation with CMR has shown prognostic implications.277 Finally, preliminary data show that myocardial fibrosis assessed with CMR is frequent in PMR and has been associated with sudden cardiac death and ventricular arrhythmias.279 Exercise echocardiography permits evaluation of changes in mitral regurgitant volume and pulmonary pressures during peak exercise and is particularly helpful in patients with discordant symptoms and regurgitation grade at rest.280,281 In asymptomatic patients with severe PMR and non-dilated LV and LA, low BNP values are associated with low mortality and can be useful during follow-up.41,282 LV dimensions and ejection fraction are considered to guide the management of patients with severe PMR. However, there is cumulative evidence showing that LV global longitudinal strain has incremental prognostic value in patients treated with surgical repair.283,284 Recently, the Mitral Regurgitation International Database (MIDA) score has been proposed to estimate the risk of all-cause mortality in patients with severe PMR due to flail leaflet, who are under medical treatment or surgically treated.285 Among the variables included in the score, LA diameter >_55 mm and LVESD >_40 mm are new thresholds that have been included in the current recommendations. Right heart catheterization is systematically used to confirm pulmonary hypertension diagnosed by echocardiography when this is the only criterion to refer the patient for surgery.

6.1.2 Indications for intervention Urgent surgery is indicated in patients with acute severe mitral regurgitation. In the case of papillary muscle rupture as the underlying disease, valve replacement is generally required. Indications for surgery in severe chronic PMR are shown in the following table of recommendations and in Figure 5. Surgery is Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026