The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Abstract

Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current randomized trials require careful interpretation. This collaborative position statement, developed by four key associations of the European Society of Cardiology—the Heart Failure Association (HFA), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Association of Cardiovascular Imaging (EACVI), and European Heart Rhythm Association (EHRA)—presents an updated practical approach to the evaluation and management of patients with HF and SMR based upon a Heart Team approach.

Impact of mitral regurgitation in patients with worsening heart failure: insights from BIOSTAT‐CHF

“…Similar results were also found in the ARIC analysis where moderate or severe MR was an independent predictor of 1‐year mortality only in patients with LVEF <50% 20 . These findings may be related to the different mechanisms and pathogenesis of MR in patients with normal or reduced LVEF so that the contribution of MR, as well as that of LV remodelling, is larger in patients with a reduced LVEF 11,29,36,37 …”

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

“…In contrast, COAPT showed a significant reduction in hospitalization for HF at 24 months (primary endpoint; HR 0.53, 95% CI 0.40–0.70) and mortality (secondary endpoint; HR 0.62, 95% CI 0.46–0.82) 613 . Differences in patient selection, concomitant MT, echocardiographic assessment, procedural issues and severity of SMR in relation to the degree of LV dilatation may be responsible for the diverging results of the MITRA‐FR and COAPT trials 614–616 . Thus, percutaneous edge‐to‐edge mitral valve repair should be considered for outcome improvement only in carefully selected patients who remain symptomatic (NYHA class II–IV) despite OMT, with moderate‐to‐severe or severe SMR (EROA ≥30 mm 2 ), favourable anatomical conditions, and fulfilling the inclusion criteria of the COAPT study (i.e.…”

Two‐year outcomes from the MitrAl ValvE RepaIr Clinical (MAVERIC) trial: a novel percutaneous treatment of functional mitral regurgitation

“…Current guidelines recommend consideration of transcatheter edge-to-edge repair for FMR following optimization of medical therapy; however, reduction in mortality and rehospitalization may be limited to patients with smaller LV end-diastolic diameters with MR as the dominant feature. [2][3][4] Surgical repair is of unclear benefit and there remains an unmet clinical need. 5 The ARTO system (MVRx Inc., San Mateo, CA, USA) is a transcatheter annular reduction therapy for the treatment of FMR and an emerging alternative to surgery with successful early results in the first phase of the MitrAl ValvE RepaIr Clinical (MAVERIC) trial (NCT03311295) in patients with enlarged ventricles and annular dilatation.…”