Clinical Scenario

This protocol is for symptomatic patients with severe atrial secondary mitral regurgitation (atrial SMR) — a functionally distinct subtype in which mitral regurgitation arises from atrial and annular remodelling rather than primary leaflet disease. It applies where atrial fibrillation (AF) and/or heart failure with preserved ejection fraction (HFpEF) is the driving clinical context.

Defining Features of This Population

Severe atrial secondary mitral regurgitation
Preserved left ventricular ejection fraction (≥50%), no regional wall motion abnormalities, no leaflet tethering
History of atrial fibrillation and/or confirmed HFpEF diagnosis

Treatment Approach — Partial Overview

For symptomatic patients on optimal medical therapy, the approach involves either a surgical intervention targeting the mitral valve — with related procedures considered alongside where indicated — or, for those not eligible for surgery, a transcatheter option. The full regimen, including eligibility criteria, sequencing, and all considerations, is available in the complete protocol.

Full algorithm, eligibility pathway, and all options available below ↓

References

DOI: 10.1093/eurheartj/ehaf194

Atrial SMR is most frequently defined by the presence of the following key criteria:
preserved LVEF (≥50%) without regional wall motion abnormalities or leaflet tethering; AND
Clinical criteria (i.e. history of AF and/or diagnosis of HFpEF) are also useful and should be taken into consideration.
MV surgery, surgical AF ablation, if indicated, and LAAO should be considered in symptomatic patients with severe atrial SMR under optimal medical therapy.
TEER may be considered in symptomatic patients with severe atrial SMR not eligible for surgery after optimization of medical therapy including rhythm control, when appropriate.

View source ↗

Treatment of Acute Mitral Regurgitation in Atrial Fibrillation: Severe Atrial Secondary MR with Preserved LVEF

References