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Let’s turn the page on mitral regurgitation

For too long, mitral regurgitation (MR) has been undertreated, compromising patient outcomes. It's 
time to deliver targeted and effective treatments for moderate-to-severe and severe MR  that improve cardiac function and change lives.1–4

Understanding MR helps ensure that your patients get the right treatment

MR is backward blood flow during left ventricular systole, which can lead to progressive symptoms if left untreated. Structural changes to the heart can lead to atrial fibrillation, heart failure (HF) and pulmonary hypertension.5,6

MR is characterised by two distinct aetiologies:

Degenerative MR (DMR) 1
Degenerative MR (DMR) 2

Primary MR (PMR)

Any MR resulting from structural deformity or damage to the leaflets, chordae or papillary muscles, causing leaflets to close insufficiently during systole.7–10 PMR affects 2% of the population11 and 24.2 million people worldwide.12

The most common cause of DMR is mitral valve prolapse, which is defined by a spectrum of lesions.11

most common cause of DMR SVG

Secondary MR (SMR) 

Any MR resulting from abnormalities/disease of the left ventricle (ventricular SMR) or left atrium (atrial SMR). There are no structural problems with the valve apparatus itself.9,10,13 Significant SMR has been shown to develop in around half of patients with myocardial infarction and up to 50% of patients with HF.14 

Isolated moderate or severe MR is associated with reduced survival and often goes untreated2,15,16 

2% most common form VHD

MR is the most common form of valvular heart disease (VHD) in the developed world, affecting 2% of people worldwide.3,10,15

VHD 19M of europe adults

MR is the second most common VHD in Europe, affecting >19 million adults >65 years old, as extrapolated from a community study in Oxfordshire, UK.12,15,17,18

49% of petients go untreated MR

Up to 49% of patients with symptomatic MR go untreated.15

Learn more about MR

Treatment options to address MR

Effective treatment of SMR starts with optimisation of medical treatment.13 For patients with severe ventricular SMR and impaired left ventricular ejection fraction (LVEF), without concomitant coronary artery disease (CAD), who remain symptomatic despite guideline-directed medical therapy (GDMT) and cardiac resynchronisation therapy (CRT), if indicated, transcatheter edge-to-edge repair (TEER) is the recommended treatment option, provided certain clinical and echocardiographic criteria* are fulfilled. Surgery may be considered in those unsuitable for TEER provided they do not have advanced heart failure.13

Symptomatic patients with severe atrial SMR under optimal medical therapy should be considered for mitral valve surgery, surgical ablation (if indicated) and left atrial appendage occlusion. TEER may be considered in those unsuitable for surgery after optimisation of medical therapy including rhythm control, when appropriate.13

*Please refer to criteria detailed in Table 7 of the European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) Guidelines for the management of valvular heart disease.13

Learn more about current treatment options
The next chapter in MR treatment is here

What is TEER?

Mitral TEER, also referred to as transcatheter mitral valve repair, is a percutaneous catheter-based approach that aims to restore mitral valve leaflet coaptation, thus reducing  MR.19

Learn more about TEER
Pascal Platform

Who should you refer to a Heart Team?

Refer patients with severe, symptomatic MR despite GDMT to a Heart Team.13

MR treatment plan

Early recognition is key.20 Patients who progress to severe disease should be referred for evaluation to a Heart Team when intervention is considered.13 The ESC/EACTS guidelines specify that symptomatic patients with severe PMR who are anatomically suitable and at high surgical risk should be considered for TEER by the Heart Team.13 Additionally, TEER is recommended in patients with severe ventricular SMR and impaired LVEF, without CAD, who remain symptomatic despite GDMT and CRT (if indicated) and fulfil certain clinical and echocardiographic criteria.* TEER may be considered in patients with severe atrial SMR who are not eligible for surgery, provided symptoms persist after optimisation of medical therapy including rhythm control, when appropriate.13 The multidisciplinary team will carefully select the right treatment option for the patient, to ensure the best possible outcome.13,20

*Please refer to criteria detailed in Table 7 of the ESC/EACTS Guidelines for the management of valvular heart disease.13

2025 ESC/EACTS Guidelines for the management of valvular heart disease13

DM patients

Class IIa/B

The following patients should be considered for TEER: 

  • Symptomatic, severe PMR
  • Anatomically suitable
  • High surgical risk, judged by the Heart Team
FMR patients

Class I/A

TEER is recommended for the following patients:

  • Sever symptomatic SMR without concomitant CAD
  • Symptomatic despite optimised GDMT and CRT (if indicated) 
  • Fulfilling specific clinical and echocardiographic criteriaa

Class IIb/Bb

The following patients may be considered for TEER: 

  • Symptomatic, severe SMR without concomitant CAD
  • Not fulfilling specific clinical and echocardiographic criteriaa
Atrial SMR patients

Class IIb/B

The following patients may be considered for TEER: 

  • Severe SMR 
  • Symptomatic after optimisation of medical therapy including rhythm control, when appropriate
  • Ineligible for surgery 

aPlease refer to criteria detailed in Table 7 of the ESC/EACTS Guidelines for the management of valvular heart disease.
bPatients may be considered after careful evaluation of LVAD or heart transplantation. Percutaneous coronary intervention followed by TEER after re-evaluation of MR may be considered in symptomatic patients with chronic severe ventricular SMR and non-complex CAD.

An update to the ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure is anticipated in 2026.21

Learn about patient eligibility
Professor Mark Petrie 

The 2025 ESC/EACTS Guidelines mark a major shift in clinical practice for patients with ventricular SMR. With a Class I recommendation for intervention and a strong emphasis on early implementation of GDMT, they clearly set a new standard of care. Following these guidelines ensures MR patients receive evidence-based, timely, and optimal treatment across Europe and beyond.*

-

Professor Mark Petrie
University of Glasgow, UK 

*Expert opinions, advice and all other information expressed represent contributors' views and not necessarily those of Edwards Lifesciences.

Book

2025 ESC/EACTS Guidelines for the management of valvular heart disease

The latest guidelines introduce pivotal changes in the management of MR.

Explore the key changes
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Help your patients start a new chapter - today

Discover a wealth of resources designed to deepen your understanding of MR and its treatment. Stay informed with our upcoming symposium announcements, access insightful discussions through our on-demand webinars, and explore the extensive TEER body of evidence.
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Exclusive resources of MR

References

  1. Makkar R, Zahr F, Chakravarty T, et al. CLASP IID trial and registry: 2-year outcomes of transcatheter repair for degenerative mitral regurgitation. JACC Cardiovasc Interv. 2025;18(19):2392–2404. doi:10.1016/j.jcin.2025.07.014.
  2. Dziadzko V, Clavel MA, Dziadzko M, et al. Outcome and undertreatment of mitral regurgitation: a community cohort study. Lancet. 2018;391(10124):960–969. doi:10.1016/s0140-6736(18)30473-2. 
  3. Enriquez-Sarano M, Benfari G, Essayagh B, et al. Mitral regurgitation: Quantify, integrate, and interpret in context. JACC Case Rep. 2022;4(19):1242–1246. doi:10.1016/j.jaccas.2022.08.032. 
  4. Spargias K, Lim DS, Makkar R, et al. Three-year outcomes for transcatheter repair in patients with mitral regurgitation from the CLASP study. Catheter Cardiovasc Interv. 2023;102(1):145–54. doi:10.1002/ccd.30686. 
  5. National Coverage Analysis. Transcatheter mitral valve repair (TMVR). Accessed 14 March 2025, https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&NCAId=297. 
  6. Penn Medicine. Mitral valve regurgitation. Accessed 14 March 2025, https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/mitral-valve-regurgitation. 
  7. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e35–e71. doi:10.1161/cir.0000000000000932. 
  8. Hamid UI, Aksoy R, Sardari Nia P. Mitral valve repair in papillary muscle rupture. Ann Cardiothorac Surg. 2022;11(3):281–289. doi:10.21037/acs-2021-ami-23. 
  9. El Sabbagh A, Reddy YNV, Nishimura RA. Mitral valve regurgitation in the contemporary era: Insights into diagnosis, management, and future directions. JACC Cardiovasc Imaging. 2018;11(4):628–643. doi:10.1016/j.jcmg.2018.01.009. 
  10. Douedi S, Douedi H. Mitral regurgitation. StatPearls. StatPearls Publishing LLC; 2025. 
  11. Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: Best practice revolution. Eur Heart J. 2010;31(16):1958–66. doi:10.1093/eurheartj/ehq222. 
  12. Pavon AG, Guglielmo M, Mennilli PM, et al. The role of cardiovascular magnetic resonance in patients with mitral regurgitation. J Cardiovasc Dev Dis. 2022;9(11):399. doi:10.3390/jcdd9110399. 
  13. 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.
  14. Vajapey R, Kwon D. Guide to functional mitral regurgitation: A contemporary review. Cardiovasc Diagn Ther. 2021;11(3):781–792. doi:10.21037/cdt-20-277. 
  15. 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. 
  16. Cardioguide. Mitral regurgitation. Accessed 14 March 2025, https://www.cardioguide.ca/mitral-regurgitation/. 
  17. Cecchetto A, Nistri S, Mele D. Primary mitral regurgitation: Answers to clinical cardiologists’ most common questions. Accessed 14 March 2025, https://www.escardio.org/Councils/Council-for-Cardiology-Practice-(CCP)/Cardiopractice/primary-mitral-regurgitation-answers-to-clinical-cardiologists-most-common-que. 
  18. Cahill TJ, Prothero A, Wilson J, et al. Community prevalence, mechanisms and outcome of mitral or tricuspid regurgitation. Heart. 2021;107(12):1003–1009. doi:10.1136/heartjnl-2020-318482. 
  19. Blackman DJ, Schlosshan D, Dawkins S, et al. Mitral valve TEER in the UK: What you need to know as TEER becomes routinely available in the NHS. Br J Cardiol. 2023;30(4):34. doi:10.5837/bjc.2023.034. 
  20. NICE. Heart valve disease presenting in adults; Investigation and management. Accessed 10 April 2025, https://www.nice.org.uk/guidance/ng208/chapter/Recommendations. 
  21. European Society of Cardiology. Guidelines publication schedule. Accessed 10 September 2025, https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/ESC-Guidelines-Publication-Schedule#.
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