What are the management options for secondary mitral regurgitation (MR)?

Management Options for Secondary Mitral Regurgitation

Guideline-directed medical therapy (GDMT) should be the first-line treatment for all patients with secondary mitral regurgitation (SMR), with transcatheter edge-to-edge repair (TEER) considered in carefully selected patients who remain symptomatic despite optimal medical therapy. 1

Initial Approach to Secondary MR

Medical Therapy

• First-line treatment: Optimize GDMT for heart failure, which includes:

  • ACE inhibitors/ARBs/ARNI (sacubitril/valsartan)
  • Beta-blockers
  • Mineralocorticoid receptor antagonists (MRA)
  • SGLT2 inhibitors
  • Ivabradine (if indicated)
  • Diuretics for symptom control 1, 2

• Cardiac Resynchronization Therapy (CRT): Should be performed for heart failure if indicated (Class IA recommendation) 1

  • Can reduce SMR severity in 40-45% of eligible patients 2

• Management of Atrial Fibrillation: Pursuit of sinus rhythm in patients with atrial fibrillation can significantly reduce MR severity 2

Advanced Interventions for Persistent Symptomatic SMR

Transcatheter Edge-to-Edge Repair (TEER)

• Consider TEER in patients with:

  • Severe SMR
  • Symptomatic heart failure (NYHA class II-IV) despite optimal GDMT
  • LVEF 20-50%
  • LV end-systolic diameter ≤70 mm
  • Recent heart failure hospitalization or elevated natriuretic peptides
  • Suitable valve anatomy for the procedure 1

• TEER contraindications:

  • Severe disability/frailty
  • Hypertrophic, restrictive, or infiltrative cardiomyopathies
  • Pulmonary artery systolic pressure >70 mmHg
  • Hemodynamic instability
  • Moderate-severe RV dysfunction
  • Mitral valve orifice area <4.0 cm² 1

Surgical Options

• Mitral valve surgery may be considered for:

  • Patients with LVEF >30% who have indications for CABG (Class IC) 1
  • Patients with LVEF ≤30% who have indications for CABG (Class IIbC) 1
  • Moderate MR with indications for CABG but no viability in posteroinferior wall (Class IIbC) 1

• Surgical approach:

  • MV repair with undersized rigid annuloplasty ring is preferred in selected patients without advanced LV remodeling (Class IIaB) 1
  • Chordal-sparing MV replacement may be considered in cases with high risk of MR recurrence 1, 3

Decision-Making Algorithm

1. Start with optimal GDMT for all patients with SMR

   • Rapid medication titration protocols to reduce heart failure hospitalization 2
   • Add CRT if indicated by guidelines

2. If symptoms persist despite optimal GDMT:

   • Confirm severity of MR (EROA ≥0.3-0.4 cm² or regurgitant volume ≥45-60 mL/beat) 1
   • Assess LV function and dimensions (LVEF 20-50%, LVESD ≤70 mm) 1

3. Heart Team evaluation to determine optimal intervention:

   • Consider TEER for patients meeting criteria with prohibitive surgical risk
   • Consider surgical repair/replacement for patients with acceptable surgical risk, especially if concomitant CABG is indicated
   • Consider other transcatheter options in clinical trials for patients not suitable for TEER or surgery 1

Important Considerations

• Multidisciplinary Heart Team approach is strongly emphasized in all guidelines for determining optimal intervention based on MR etiology, patient comorbidities, and surgical risk 1

• Imaging assessment: CMR may be useful to quantify LV/RV function, chamber size, and MR severity when echocardiographic measurements are ambiguous 1

• Biomarkers: Serum biomarkers (BNP/NT-proBNP) may help guide optimal timing of intervention in symptomatic patients 1

• Outcomes: TEER has shown a number needed to treat of 3.1 to reduce heart failure hospitalization and 5.9 to reduce all-cause death in appropriately selected patients 2

• Underutilization: Despite evidence of benefit, TEER remains underused in many countries compared to Germany, Switzerland, and the USA 2

Emerging Options

• Transcatheter mitral valve replacement and percutaneous annuloplasty are currently being evaluated in clinical trials and may offer additional options for patients unsuitable for current interventions 1, 4

• Left ventricular assist devices may be considered in end-stage heart failure patients with significant SMR 3