This protocol addresses the management of severe ventricular secondary mitral regurgitation (SMR) occurring alongside concomitant coronary artery disease — a scenario that shapes both the treatment priorities and the decision for surgical intervention.
The patient presents with severe ventricular secondary mitral regurgitation and concomitant coronary artery disease. This combination requires coordinated management of both the underlying ventricular dysfunction driving the secondary MR and the coexisting coronary disease.
Guideline recommendations specifically address patients with severe ischaemic ventricular SMR requiring coronary revascularization: mitral valve surgery at the time of coronary artery bypass grafting (CABG) is recommended — unless the patient is at high surgical risk and/or coronary anatomy is suitable for percutaneous coronary intervention (PCI).
Guideline-directed medical therapy (GDMT) for heart failure is recommended prior to any mitral valve intervention. The approach involves a combination of medical therapies at maximum tolerated doses —
MV surgery is recommended in patients with severe ventricular SMR undergoing CABG.
In patients with severe ischaemic ventricular SMR and concomitant CAD requiring coronary revascularization, MV surgery at the time of CABG is recommended, unless the patient is at high surgical risk and/or the coronary anatomy is suitable for PCI.
In patients with ventricular SMR, GDMT for the treatment of HF is recommended prior to any MV intervention.
The combination of ACE-Is/ARBs or angiotensin receptor/neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium–glucose co-transporter 2 inhibitors (SGLT2is) at the maximum tolerated doses is recommended according to the HF Guidelines.
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