Clinical Scenario

This protocol covers patients with severe ventricular secondary mitral regurgitation (SMR) who are symptomatic and have an impaired left ventricular ejection fraction (LVEF <50%), without concomitant coronary artery disease.

Ventricular SMR is the more prevalent form of secondary MR and is associated with a worse long-term prognosis.

Treatment Approach

The recommended first step is guideline-directed medical therapy (GDMT) for heart failure at the maximum tolerated doses — this is prioritised before any valve intervention. The regimen involves a combination of several medication classes targeting the neurohormonal and metabolic pathways of heart failure. Depending on certain cardiac parameters, a device-based intervention may also be considered as part of heart failure management. The full sequence, agents, and criteria are defined in the complete protocol.

Clinical goal: Improvement of SMR severity after 1–3 months of optimised GDMT.

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).
Ventricular SMR is more common and associated with worse long-term prognosis.
About 40% of patients with ventricular SMR experience improvement of SMR severity after 1–3 months of optimized GDMT.

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Treatment of Mitral Regurgitation with Impaired Left Ventricular Ejection Fraction in Symptomatic Severe Ventricular Secondary MR

Clinical Scenario

Treatment Approach

References