This protocol addresses haemodynamically stable, symptomatic patients with severe ventricular secondary mitral regurgitation (SMR) and impaired left ventricular ejection fraction (LVEF <50%), without concomitant coronary artery disease, in whom first-line optimized therapy has not resolved persistent significant SMR.
Ventricular SMR arises from left ventricular dysfunction rather than intrinsic valve disease. When LVEF is impaired (<50%) and severe SMR persists, this phenotype carries a worse long-term prognosis.
The relevant population is the haemodynamically stable, symptomatic patient in whom optimized medical therapy — and cardiac resynchronization therapy when indicated — has not substantially reduced SMR severity.
First-line management is guideline-directed medical therapy (GDMT) for heart failure, combining agents that address neurohormonal pathways, along with cardiac resynchronization therapy when criteria are met.
Escalation to this protocol is indicated when SMR severity has not improved after 1–3 months of optimized GDMT — the defined threshold for non-response that triggers the next step.
When GDMT has not reduced SMR severity, a catheter-based interventional approach is available for patients who fulfil specific clinical and echocardiographic eligibility criteria.
Full eligibility criteria, the complete decision pathway, and the alternative for non-eligible patients are defined in the structured protocol.
DOI: 10.1093/eurheartj/ehaf194
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.
Ventricular SMR is more common and associated with worse long-term prognosis.
Transcatheter edge-to-edge repair is therefore recommended to reduce HF hospitalizations, and improve quality of life, in symptomatic patients with persisting severe SMR despite optimized GDMT fulfilling specific clinical and echocardiographic criteria (Table 7).
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