Clinical Treatment Guidelines for Severe Annular Mitral Valve Regurgitation

Classification and Diagnosis

The European Society of Cardiology defines primary MR as a direct valve abnormality, and secondary MR as a result of LV geometry alterations with structurally normal valve components 3
Echocardiography is essential for diagnosis, determining severity, etiology, and valve anatomy/function, as recommended by the European Heart Journal 3
An integrative approach using multiple parameters is recommended for assessing MR severity, rather than relying on a single measurement, according to the American College of Cardiology 4, 5

The European Society of Cardiology recommends surgery for symptomatic patients with severe MR who are symptomatic (NYHA class II-IV) with LVEF >30% 1, 2
The European Society of Cardiology also recommends surgery for asymptomatic patients with severe primary MR when there is LV dysfunction (LVEF ≤60%) and/or LV end-systolic diameter ≥40 mm 2, 6
Mitral valve repair is strongly preferred over replacement when anatomically feasible and durable repair is likely, as recommended by the European Society of Cardiology 1, 2

The European Society of Cardiology recommends optimizing guideline-directed medical therapy for heart failure, including ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists 1
The European Society of Cardiology also recommends considering SGLT2 inhibitors and sacubitril/valsartan for patients with secondary MR 1, 7
Surgery is recommended for patients with severe secondary MR undergoing CABG with LVEF >30%, as recommended by the European Society of Cardiology 3

The European Society of Cardiology recommends considering transcatheter edge-to-edge repair (TEER) for symptomatic patients with severe primary MR at high/prohibitive surgical risk with favorable anatomy and life expectancy ≥1 year 1
The European Society of Cardiology also recommends considering TEER for patients with severe secondary MR, LVEF >30%, persistent symptoms despite optimal medical therapy, and no indication for coronary revascularization 1, 7

The European Society of Cardiology recommends clinical and echocardiographic follow-up every 6-12 months for asymptomatic patients with severe MR 2
The European Society of Cardiology also recommends considering exercise echocardiography, biomarkers, and novel measurements of LV function for risk stratification 2
For acute severe MR, the European Society of Cardiology recommends vasodilator therapy, inotropic support if hemodynamically unstable, and mechanical support with intra-aortic balloon pump may be needed 1, 7