Two in ten severe MR patients can die within 1 year without intervention.4
Treatment options
Treatment options vary depending on the type of mitral regurgitation (MR): primary MR (PMR) or secondary MR (SMR). SMR can be classified as atrial or ventricular, each with distinct characteristics and therapeutic implications.1 The updated ESC/EACTS Guidelines for the management of valvular heart disease introduce a decision-making algorithm designed to support selecting the most appropriate treatment pathway for individual patients.1
PMR
Despite millions of cases in an aging population, PMR is still substantially undertreated.2
Only 15% of patients aged 80 years or older, diagnosed with moderate or severe MR (PMR/SMR), underwent valve surgery.2
Surgery saves lives, but many patients do not meet the criteria.2,3
96% 1-year survival rates for patients with severe symptomatic MR who received surgical intervention.3
49% of patients with symptomatic MR are denied surgery, influenced by older age, comorbidities and impaired left ventricular ejection fraction (LVEF).3,4
A less invasive option is needed for patients at high surgical risk.5
A patient with severe heart failure, for them undergoing open heart surgery is a huge strain.*
-Dr.med. Leonhard Schneider
University Heart Centre Ulm, Ulm, Germany
*Expert opinions, advice and all other information expressed represent contributors' views and not necessarily those of Edwards Lifesciences.
Transcatheter edge-to-edge repair (TEER) has shown significant and sustained MR reduction and durable patient benefits1,6
From the 2-year outcomes of the CLASP IID trial, TEER has shown significant and sustained MR reduction in patients with severe, symptomatic PMR at prohibitive surgical risk at 2 years.6
79% of patients achieved significant and sustained MR reduction (MR ≤1+)*
88% of patients achieved NYHA class I/II
89% freedom from cardiovascular mortality
+17 points KCCQ-OS improvement
*Data from unpaired analysis. The presented MR reduction was achieved using the PASCAL system.
KCCQ-OS: Kansas City Cardiomyopathy Questionnaire Overall Summary Score; MR: mitral regurgitation; NYHA: New York Heart Association.
2025 ESC/EACTS Guidelines for the management of valvular heart disease support TEER for patients with severe PMR with the following recommendation:1
The following patients should be considered for TEER:
- Symptomatic patients with severe PMR who are anatomically suitable and at high surgical risk according to the Heart Team
EACTS: European Association for Cardio-Thoracic Surgery; ESC: European Society of Cardiology.
SMR
Severe SMR is seen in about 25% of heart failure (HF) with reduced ejection fraction (HFrEF) patients.7 Four drug classes are proving to reduce morbidity and mortality in patients with chronic HFrEF8
The conventional approach to the implementation of the core pharmacological treatments for HFrEF may not be optimal, and alternative approaches, such as rapid sequencing, could lead to a substantial reduction in lives lost and hospitalisations for worsening HF.9
Simplified treatment algorithms for HFrEF and specific HFrEF phenotypes are provided in the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic HF.10
Convention: Sequential approach8
Initiation of all four foundation drug classes one after the other; up-titration to target dose at each step.
New: Rapid sequencing8
Initiation of all four foundation drug classes within 4 weeks; up-titration to target doses after all steps.
Could improve the implementation of treatments that reduce morbidity and mortality.
ACE-I: angiotensin-converting-enzyme inhibitors; ARB: angiotensin receptor blocker; ARNI: angiotensin receptor neprilysin inhibitor; MRA: mineralocorticoid receptor antagonist; SGLT2i: sodium–glucose co-transporter 2.
All foundation drug classes are Class I recommendations.
One should up-titrate them as fast as possible to achieve the best tolerated doses and, if possible, the maximum recommended doses*
-Professor Michael Böhm, MD
Saarland University Hospital, Homburg, Germany
*Expert opinions, advice and all other information expressed represent contributors' views and not necessarily those of Edwards Lifesciences.
Barriers to guideline-directed medical therapy (GDMT) implementation11
In a real-world setting, up to 42% of HFrEF patients are not optimally managed on GDMT.12
29% increased risk of mortality for every year of inadequate GDMT.12
When symptoms of severe SMR persist despite GDMT, and surgery isn't an option, minimally invasive treatments are available1
2025 ESC/EACTS Guidelines for the management of valvular heart disease support TEER for patients with severe SMR with the following recommendations:1
TEER is recommended for the following patients:
- Haemodynamically stable, symptomatic patients with impaired LVEF (<50%) and persistent severe ventricular SMR, despite optimised GDMT and CRT (if indicated), fulfilling specific clinical and echocardiographic criteria* to reduce HF hospitalisations and improve quality of life
The following patients may be considered for TEER:
- Symptomatic patients with severe atrial SMR not eligible for surgery after optimisation of medical therapy including rhythm control, when appropriate
- Selected symptomatic patients with severe ventricular SMR not fulfilling the specific clinical and echocardiographic criteria,* after careful evaluation of LVAD or heart transplantation
*Anatomy deemed suitable for M-TEER; NYHA class ≥ II, LVEF 20%–50%; LVESD ≤70 mm; at least one HF hospitalisation within the previous year or increased natriuretic peptide levels (BNP ≥300 pg/mL or NT-proBNP ≥1000 pg/mL); SPAP ≤70 mmHg; no severe RV dysfunction; no Stage D or advanced HF; no CAD requiring revascularisation; no severe aortic valve and/or tricuspid valve disease; no hypertrophic, restrictive, or infiltrative cardiomyopathies.
BNP: brain natriuretic peptide; CAD: coronary artery disease; CRT: cardiac resynchronisation therapy; HF: heart failure; LVAD: left ventricular assist device; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; M-TEER: mitral transcatheter edge-to-edge repair; NT-proBNP: N-terminal pro-B-type natriuretic protein; NYHA: New York Heart Association; RV: right ventricle/right ventricular; SPAP: systolic pulmonary artery pressure.
A Class I indication for TEER for ventricular SMR is a major advance. This means a treatment that is mandatory for our patients with heart failure and SMR who fulfil the guidelines criteria, and that is well established thanks to evidence from two clinical trials. I think it's a major step forward for our patients.*
-Professor Marco Metra
University of Brescia, Brescia, Italy
*Expert opinions, advice and all other information expressed represent contributors' views and not necessarily those of Edwards Lifesciences.
2025 ESC/EACTS Guidelines for the management of valvular heart disease
The latest guidelines introduce pivotal changes in the management of MR.
Help your patients start a new chapter with TEER
References
- Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the task force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2025; doi: 10.1093/eurheartj/ehaf194. Epub ahead of print.
- Taramasso M, Gaemperli O, Maisano F. Treatment of degenerative mitral regurgitation in elderly patients. Nat Rev Cardiol. 2015;12(3):177–83. doi:10.1038/nrcardio.2014.210.
- Mirabel M, Iung B, Baron G, et al. What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery? Eur Heart J. 2007;28(11):1358–65. doi:10.1093/eurheartj/ehm001.
- Welman MJM, Streukens SAF, Mephtah A, et al. Outcomes of mitral valve regurgitation management after expert multidisciplinary valve team evaluation. J Clin Med. 2024;13(15):doi:10.3390/jcm13154487. doi:10.3390/jcm13154487.
- Iung B, Urena M. New insights into transcatheter edge-to-edge repair: Filling a gap for undertreatment of primary mitral regurgitation in the elderly? Eur Heart J. 2022;doi:10.1093/eurheartj/ehac039.
- Makkar R. CLASP IID randomised trial and registry: Two-year outcomes of transcatheter edge-to-edge repair for degenerative mitral regurgitation. PCR London Valves, 24–26 November 2024, London, UK.
- Bartko PE, Heitzinger G, Pavo N, et al. Burden, treatment use, and outcome of secondary mitral regurgitation across the spectrum of heart failure: observational cohort study. BMJ. 2021;373:n1421. doi:10.1136/bmj.n1421.
- Packer M, McMurray JJV. Rapid evidence-based sequencing of foundational drugs for heart failure and a reduced ejection fraction. Eur J Heart Fail. 2021;23(6):882–894. doi:10.1002/ejhf.2149.
- Shen L, Jhund PS, Docherty KF, et al. Accelerated and personalized therapy for heart failure with reduced ejection fraction. Eur Heart J. 2022;43(27):2573–2587. doi:10.1093/eurheartj/ehac210.
- McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2021;42(36):3599–726. doi:10.1093/eurheartj/ehab368.
- Malgie J, Clephas PRD, Brunner-La Rocca HP, et al. Guideline-directed medical therapy for HFrEF: Sequencing strategies and barriers for life-saving drug therapy. Heart Fail Rev. 2023;28(5):1221–1234. doi:10.1007/s10741-023-10325-2.
- McCullough PA, Mehta HS, Barker CM, et al. Mortality and guideline-directed medical therapy in real-world heart failure patients with reduced ejection fraction. Clin Cardiol. 2021;44(9):1192–1198. doi:10.1002/clc.23664.
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