Treatment of Acute Mitral Regurgitation with Impaired Left Ventricular Ejection Fraction in Severe Ventricular Secondary Mitral Regurgitation
Severe ventricular secondary mitral regurgitation (SMR) presenting alongside impaired left ventricular ejection fraction (LVEF <50%) and no concomitant coronary artery disease represents a specific clinical phenotype requiring a structured medical-first approach.
Clinical scenario
Impaired LVEF (<50%) with persistent severe ventricular secondary mitral regurgitation, in the absence of concomitant coronary artery disease. Guideline-directed optimisation of heart failure therapy is required before any mitral valve intervention is considered.
Treatment approach
The first step is guideline-directed medical therapy (GDMT) for heart failure, advanced to maximum tolerated doses. Depending on specific criteria, device-based therapy may also be indicated as part of heart failure management — the complete structured regimen is available in the full protocol.
References
DOI: 10.1093/eurheartj/ehaf194
- 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.
- Cardiac resynchronization therapy (CRT) should also be considered as part of HF management before an MV intervention according to HF guideline criteria (LVEF ≤35% and wide QRS).
- TEER is recommended to reduce HF hospitalizations and improve quality of life in haemodynamically stable, symptomatic patients with impaired LVEF (<50%) and persistent severe ventricular SMR, despite optimized GDMT and CRT (if indicated), fulfilling specific clinical and echocardiographic criteria.
View source ↗