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Table 3 Continued

New or Revised Recommendations in 2017 version Class Recommendations in 2021 version Class Revised Surgery should be considered in asymptomatic patients with preserved LV function (LVESD

<45 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertension (SPAP at rest >50 mmHg). IIa 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 hypertension (SPAP at rest >50 mmHg). IIa

Revised Surgery should be considered in asymptomatic

patients with preserved LVEF (>60%) and LVESD 4044 mm when a durable repair is likely, surgical risk is low, the repair is performed in a Heart Valve Centre and at least one of the following findings is present: • flail leaflet or; • presence of significant LA dilatation (volume index >_60 mL/m2 BSA) in sinus rhythm. IIa Surgical mitral valve repair should be considered in

low-risk asymptomatic patients with LVEF >60%, LVESD <40 mm and significant LA dilatation (volume index >_60 mL/m2 or diameter >_55 mm) when performed in a Heart Valve Centre and a durable repair is likely. IIa

Section 6. Indications for mitral valve intervention in chronic severe secondary mitral regurgitation New Valve surgery/intervention is recommended only

in patients with severe SMR who remain symptomatic despite GDMT (including CRT if indicated) and has to be decided by a structured collaborative Heart Team. I

Patients with concomitant coronary artery or other cardiac disease requiring treatment New In symptomatic patients, who are judged not

appropriate for surgery by the Heart Team on the basis of their individual characteristics, PCI (and/or TAVI) possibly followed by TEER (in case of persisting severe SMR) should be considered. IIa

Revised Surgery is indicated in patients with severe SMR

undergoing CABG and LVEF >30%. I Valve surgery is recommended in patients under-

going CABG or other cardiac surgery. I

Patients without concomitant coronary artery or other cardiac disease requiring treatment Revised When revascularization is not indicated and surgi-

cal risk is not low, a percutaneous edge-to-edge procedure may be considered in patients with severe secondary mitral regurgitation and LVEF >30% who remain symptomatic despite optimal medical management (including CRT if indicated) and who have a suitable valve morphology by echocardiography, avoiding futility. IIb TEER should be considered in selected sympto-

matic patients, not eligible for surgery and fulfilling criteria suggesting an increased chance of responding to the therapy. IIa

Revised In patients with severe SMR and LVEF <30% who remain symptomatic despite optimal medical man-

agement (including CRT if indicated) and who have no option for revascularization, the Heart Team may consider a percutaneous edge-to-edge procedure or valve surgery after careful evaluation for a ventricular assist device or heart transplant according to individual patient characteristics. IIb In high-risk symptomatic patients not eligible for surgery and not fulfilling the criteria suggesting an

increased chance of responding to TEER, the Heart Team may consider in selected cases a TEER procedure or other trans-catheter valve therapy if applicable, after careful evaluation for ventricular assist device or heart transplant. IIb

Section 8: Indications for intervention in primary tricuspid regurgitation Revised Surgery should be considered in asymptomatic or

mildly symptomatic patients with severe isolated primary tricuspid regurgitation and progressive RV dilatation or deterioration of RV function. IIa Surgery should be considered in asymptomatic or

mildly symptomatic patients with isolated severe primary tricuspid regurgitation and RV dilatation who are appropriate for surgery. IIa

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