This collaborative position statement, developed by four key associations of the European Society of Cardiology, presents a practical, Heart Team-based approach to the evaluation and management of patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF) and secondary mitral regurgitation (SMR). The following are key points to remember:

1. SMR is common among patients with HF with reduced LVEF and is associated with an adverse prognosis.
2. The pathophysiology of SMR is related to:
   • Increased mitral leaflet tethering forces (with potential contributions from LV dilation, sphericity, and segmental dyskinesia; papillary muscle displacement, dyssynchrony, and asymmetry; and annular dilation and flattening),
   • Decreased mitral closing forces (with potential contributions from reduced LV contractility, LV dyssynchrony, increased left atrial pressure, and reduced mitral annular contraction), and
   • Altered mitral valve function (with potential contributions from decreased area growth and increased thickening).
3. The severity of SMR should be assessed by experienced echocardiographers using an integrated, multi-parametric approach that includes assessment of the mitral valve (including leaflet length, tethering, coaptation depth, and calcification; valve area; and the SMR jet location and severity).
4. Because of limitations associated with quantitation of SMR using the proximal isovelocity surface area (PISA) method with an assumed circular regurgitant orifice, SMR severity should be assessed using multiple parameters, including the vena contracta size, pulmonary vein flow reversal, and PISA radius and regurgitant orifice area. In addition, three-dimensional (3D) assessment of the vena contracta area should be used if there is persistent diagnostic uncertainty.
5. Patients with symptomatic HF and moderate or severe SMR should be referred to a multidisciplinary Heart Team. The Heart Team should include a heart failure specialist, a cardiovascular imaging specialist, a cardiac electrophysiologist, an interventional cardiologist with expertise in transcatheter mitral valve intervention, and a cardiac surgeon with experience in mitral valve surgery.
6. The Heart Team should first evaluate and optimize guideline-directed medical therapy (GDMT) for HF. After this, consideration should be given to the respective roles and the order of their implementation of intervention including cardiac resynchronization therapy (CRT), coronary revascularization, transcatheter mitral intervention, and surgical intervention (mitral repair, ventricular assist systems, or transplantation).
7. Other than pharmacological therapy or circulatory support, decisions concerning the treatment for SMR ideally should be made in stable patients without fluid overload or the need for inotropic support.
8. Surgical treatment of severe SMR should be considered in operable patients with coronary artery disease requiring surgical revascularization.
9. Transcatheter edge-to-edge mitral repair is an evidence-based treatment option in patients with severe SMR who remain symptomatic despite optimized GDMT (including CRT when indicated) and who have been carefully selected by a multidisciplinary Heart Team.
10. Circulatory support devices and cardiac transplantation should be considered in patients with advanced left and/or right ventricular failure.
11. Interventions for SMR should be avoided in patients with a life expectancy <1 year due to conditions unrelated to SMR.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Implantable Devices, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Heart Transplant, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Mitral Regurgitation

Keywords: Atrial Pressure, Cardiac Resynchronization Therapy, Cardiac Surgical Procedures, Cardiology Interventions, Coronary Artery Disease, Dilatation, Dyskinesias, Echocardiography, Heart Failure, Heart Transplantation, Heart Valve Diseases, Myocardial Revascularization, Mitral Valve Insufficiency, Papillary Muscles, Stroke Volume

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