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Figure 20 Management of secondary mitral regurgitation in patients with heart failure with reduced ejection fraction. CRT, cardiac resynchronization therapy; FMT, foundational medical therapy; HF, heart failure; LVAD, left ventricular assist device; MR, mitral regurgitation; TEER, transcatheter edge-to-edge repair. Colours refer to class of recommendation. aSee Table 19. bSee Figure 10.

Table 19 Selection criteria for mitral transcatheter edge-to-edge repair in heart failure with reduced ejection fraction

Clinical and echocardiographic criteria Optimized FMT and other GDIT (i.e. CRT) if needed NYHA class ≥II At least one HFH within the last year OR Increased natriuretic peptide levels (BNP ≥300 pg/mL or NT-proBNP ≥1000 pg/mL) No stage D (advanced) HF No CAD requiring revascularization No hypertrophic, restrictive, or infiltrative cardiomyopathies LVEF 20%–50% LVESD ≤70 mm Anatomy deemed suitable for mitral TEER sPAP ≤70 mmHg No severe RV dysfunction No severe aortic and/or tricuspid valve disease © ESC 2026 BNP, B-type natriuretic peptide; CAD, coronary artery disease; CRT, cardiac resynchronization therapy; FMT, foundational medical therapy; GDIT, guideline-directed interventional therapy; HF, heart failure; HFH, heart failure hospitalization; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic diameter; TEER, transcatheter edge-to-edge repair; NT-proBNP, N-terminal pro-B-type natriuretic peptide; NYHA, New York Heart Association; RV, right ventricular; sPAP, systolic pulmonary artery pressure. Downloaded from academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehag100/8766302 by guest on 31 August 2026