fig3

Figure 3. Revised algorithm for secondary mitral regurgitation management in heart failure. Symptomatic, NYHA Class II-IV. Evaluation of clinical context, symptomatology, etiology of MR, and MR severity using a multiparametric approach. *ESC/EACTS/HFA Guidelines; §ACC/AHA/HFSA Guidelines. a: in patients undergoing CABG or AVR, ACC/AHA/HFSA Guidelines do not consider baseline LVEF in the therapeutic decision-making process for concomitant valvular surgery; b: according to ACC/AHA/HFSA Guidelines, it is reasonable to choose chordal-sparing mitral valve replacement for chronic severe ischemic SMR (COR IIa), whereas mitral valve repair or replacement may be considered for chronic severe secondary MR (COR IIb) in patients undergoing isolated mitral surgery. ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; ARNI: angiotensin receptor neprilysin inhibitor; AVR: aortic valve replacement; CABG: coronary artery by-pass graft; CHF: chronic heart failure; COPD: chronic obstructive pulmonary disease; COR: class of recommendation; CRT: cardiac resynchronization therapy; eGFR: estimated glomerular filtration rate; EROA: effective regurgitant orifice area; GDMT: guideline-directed medical therapy; HF: heart failure; HFrEF: heart failure with reduced ejection fraction; HTx: heart transplantation; LBBB: left bundle branch block; Log EuroSCORE: Logistic European System for Cardiac Operative Risk Evaluation; L-VAD: left ventricular assist device; LVEDV: left ventricular end-diastolic volume; LVEF: left ventricular ejection fraction; MR: mineralocorticoid receptor; NT-proBNP: N-terminal pro-B type natriuretic peptide; NYHA: New York Heart Association; SMR: secondary mitral regurgitation; TAPSE: tricuspid annular plane systolic excursion. Adapted and modified from Godino et al.^[7]