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Symptoms despite GDMT

Management of patients with chronic severe secondary mitral regurgitation

Appropriate for surgery on the base of individual patient characteristicsa Persisting severe

SMR and symptoms

N Y

Y Severe comorbidities or life expectancy < 1 year

N

CAD or other cardiac disease requiring treatment

PCI/TAVI

Appropriate for valve surgery

Fulfilling criteria suggesting

an increased chance of responding to TEERc

HTx/LVAD Palliative care TEER Close follow-up

TEER in selected cases or other transcatheter valve therapy if applicable (for symptoms improvement), after careful evaluation for HTx/LVAD MV surgeryb

N

Referral to Heart Team GDMT optimization CRT when indicated (ESC HF Guidelines)

CABG or other cardiac

surgery

AND

MV surgery End stage

LV/RV failure N Palliative

care

Y N

Y N

Y Y N

Y

Figure 6 Management of patients with chronic severe secondary mitral regurgitation. CAD = coronary artery disease; CABG= coronary artery bypass grafting; CRT = cardiac resynchronization therapy; ESC = European Society of Cardiology; GDMT = guideline-directed medical therapy; HF= heart failure; HTx = heart transplantation; LVAD= left ventricular assist devices; LV= left ventricle/left ventricular; LVEF= left ventricular ejection fraction; MV = mitral valve; PCI = percutaneous coronary intervention; RV = right ventricle/right ventricular; SMR = secondary mitral regurgitation; TAVI= transcatheter aortic valve implantation; TEER: transcatheter edge-to-edge repair. aLVEF, predicted surgical risk, amount of myocardial viability, coronary anatomy/target vessels, type of concomitant procedure needed, TEER eligibility, likelihood of durable surgical repair, need of surgical mitral replacement, local expertise. bParticularly when concomitant tricuspid valve surgery is needed. cCOAPT criteria (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation): see Supplementary Table 7. Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026