This protocol covers patients with severe ventricular secondary mitral regurgitation (SMR) who are symptomatic and have impaired left ventricular ejection fraction (LVEF <50%), without concomitant coronary artery disease. Ventricular SMR is more common than other secondary forms and carries a worse long-term prognosis.
When LVEF falls below 50% in the setting of symptomatic severe ventricular SMR, specific clinical and echocardiographic criteria determine which interventions are appropriate. The absence of obstructive coronary disease further narrows the differential and focuses the management pathway.
Patients who meet defined criteria and remain symptomatic despite optimised medical therapy represent a distinct population requiring structured, evidence-based escalation.
In selected patients with severe ventricular SMR who have progressed to advanced heart failure, the protocol addresses specific surgical or device-based interventions. The complete regimen — including full selection criteria, sequencing, and all clinical decision points — is available below.