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Atrial SMR is most frequently defined by the presence of the following key criteria:513,578–580,586–590
• preserved LVEF (≥50%) without regional wall motion abnormalities or leaflet tethering; AND • no or mildly dilated LV cavity [LV end-diastolic dimension of <56 mm in women and <63 mm in men; indexed LV end-diastolic volume of <71 mL/m2 (in women) or <79 mL/m2 (in men)]; AND • mitral annulus (MA) dilatation [anteroposterior (AP) diameter of >35 mm]; AND • enlarged LA (LAVI >34 mL/m2).
Echocardiography frequently reveals normal leaflet motion with planar coaptation, and normal leaflet morphology with a central MR jet in atrial SMR. However, at advanced stages, an overlap between atrial and ventricular SMR criteria can be observed in the case of late LV damage due to continuous volume overload.591,592 Clinical criteria (i.e. history of AF and/or diagnosis of HFpEF) are also useful and should be taken into consideration. 9.2.4 Management of ventricular secondary mitral
regurgitation 9.2.4.1. Medical and device therapy In patients with ventricular SMR, GDMT for the treatment of HF is recommended prior to any MV intervention.339,340 The combination of ACE-Is/ARBs or angiotensin receptor/neprilysin inhibitors, betablockers, mineralocorticoid receptor antagonists, and sodium–glucose co-transporter 2 inhibitors (SGLT2is) at the maximum tolerated doses is recommended according to the HF Guidelines.340 Initiation and uptitration of neurohormonal drugs need to be tailored according to the patient profile, mainly based on BP, heart rate, potassium levels, and renal function.593 Notably, GDMT up-titration must be rapid (within 6 weeks) and take place in the context of close follow-up visits, especially in the case of a recent hospitalization for acute HF.594 About 40% of patients with ventricular SMR experience improvement of SMR severity after 1–3 months of optimized GDMT.595,596 Cardiac resynchronization therapy (CRT) should also be considered as part of HF management before an MV intervention according to HF guideline criteria (LVEF ≤35% and wide QRS).597,598 Although no dedicated RCTs
≥
Figure 12 Most frequently used criteria for the diagnosis of atrial secondary mitral regurgitation. AO, aorta; AP, anteroposterior; HFpEF, heart failure with preserved ejection fraction; LA, left atrium/left atrial; LAVI, left atrial volume index; LV, left ventricle/left ventricular; LVEF, left ventricular ejection fraction; MA, mitral annulus; MR, mitral regurgitation; MV, mitral valve; SMR, secondary mitral regurgitation. aLV end-diastolic dimension of <56 mm in females and <63 mm in males; indexed LV end-diastolic volume <71 mL/m2 (in women) or <79 mL/m2 (in men). bAdditional echocardiographic criteria for atrial SMR may no longer be fulfilled in advanced stages. Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026
