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.............. recommended in patients with symptomatic severe PMR and acceptable surgical risk according to the Heart Team decision. The presence of LVEF <_60%, LVESD >_40 mm,285,286 LA volume >_60 mL/m2 or diameter >_55 mm,287,288 systolic pulmonary arterial pressure (SPAP) >50 mmHg,289 and AF290,291 have been associated with worse outcomes and are considered triggers for intervention regardless of symptomatic status.292 In the absence of these criteria, watchful waiting is a safe strategy in asymptomatic patients with severe PMR and ideally should be performed in a Heart Valve Clinic. When surgery is considered, mitral valve repair is the surgical intervention of first choice when the results are expected to be durable according to the Heart Team evaluation since it is associated with better survival compared to mitral valve replacement.293,294 PMR due to segmental valve prolapse can be repaired with a low risk of recurrence and reoperation.294296 The reparability of rheumatic lesions, extensive valve prolapse and to a greater extent leaflet calcification or extensive annular calcification is more challenging.297,298 Patients requiring a predictably complex repair should undergo surgery in experienced repair centres with high repair rates, low operative mortality, and a record of durable results. When repair is not feasible, mitral valve replacement with preservation of the subvalvular apparatus is favoured. Transcatheter mitral valve implantation for severe PMR is a safe alternative in patients with contraindications for surgery or high operative risk.299302 TEER is the most evidenced, while the safety and efficacy of other techniques have been demonstrated in smaller series.303306 The efficacy of more recent TEER system iterations307

will be investigated in high-risk (MITRA-HR study NCT03271762)308 and intermediate-risk patients (REPAIR-MR study NCT04198870).

Table 7 Severe mitral regurgitation criteria based on 2D echocardiography

Primary mitral regurgitation Secondary mitral regurgitation

Qualitative Mitral valve morphology Flail leaflet, ruptured papillary muscle, severe

retraction, large perforation Normal leaflets but with severe tenting, poor leaflet coaptation

Colour flow jet area Large central jet (>50% of LA) or eccentric wall

impinging jet of variable size Large central jet (>50% of LA) or eccentric wall impinging

jet of variable size

Flow convergence Large throughout systole Large throughout systole Continuous wave Doppler jet Holosystolic/dense/triangular Holosystolic/dense/triangular Semiquantitative Vena contracta width (mm) >_7 (>_8 mm for biplane) >_7 (>_8 mm for biplane) Pulmonary vein flow Systolic flow reversal Systolic flow reversal Mitral inflow E-wave dominant (>1.2 m/s) E-wave dominant (>1.2 m/s) TVI mitral/TVI aortic >1.4 >1.4 Quantitative EROA (2D PISA, mm2) >_40 mm2 >_40 mm2 (may be >_30 mm2 if elliptical regurgitant orifice area) Regurgitant volume (mL/beat) >_60 mL >_60 mL (may be >_45 mL if low flow conditions) Regurgitant fraction (%) >_50% >_50% Structural Left ventricle Dilated (ESD >_40 mm) Dilated Left atrium Dilated (diameter >_55 mm or volume >_60 mL/m2) Dilated 2D = two-dimensional; ESD = endsystolic diameter; EROA = effective regurgitant orifice area; LA = left atrium; PMR = primary mitral regurgitation; SMR = secondary mitral regurgitation; PISA = proximal isovelocity surface area; TVI = time-velocity integral. Adapted from Lancellotti P et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2013;14:611644. Copyright (2013) by permission of Oxford University Press on behalf of the European Society of Cardiology. Reproduced from Zoghbi WA et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2017;30:303371. Copyright (2017), with permission from the American Society of Echocardiography. ESC/EACTS 2021

Recommendations on indications for intervention in severe primary mitral regurgitation

Recommendations Classa Levelb

Mitral valve repair is the recommended surgical technique when the results are expected to be durable.293296 I B Surgery is recommended in symptomatic patients who are operable and not high risk.293296 I B Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD >_40 mm and/or LVEF <_60%).277,286,292 I B Surgery should be considered in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertensionc (SPAP at rest >50 mmHg).285,289 IIa B

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