Surgical and interventional management of mitral valve regurgitation: A position statement from the European society of cardiology working groups on cardiovascular surgery and valvular heart disease

Surgical and interventional treatment for mitral regurgitation (MR) requires a multidisciplinary approach. Experienced operators in high volume centers with a dedicated Heart Team obtain best outcomes. • Surgical repair is the reference standard treatment in primary MR. Timely surgery is associated with excellent outcome and restoration of normal life expectancy. Percutaneous procedures should be reserved for high-risk or inoperable symptomatic patients. • The choice of treatment in secondary MR is more controversial: - Surgical correction can improve symptoms and quality of life, and reverse left ventricular (LV) remodelling in selected patients. However, a clear prognostic benefit in comparison with optimal medical therapy has not been demonstrated. Undersized annuloplasty might offer a satisfactory result if performed before the onset of severe LV dilatation and in the absence of echocardiographic predictors of postoperative residual or recurrent MR. Otherwise, mitral valve (MV) replacement with preservation of the sub-valvular apparatus is preferable. - Percutaneous edge-to-edge (EE) repair for secondary MR is a low-risk option to reduce symptoms and induce reverse LV remodelling but is commonly associated with residual and recurrent MR. The procedure should be reserved for patients who have significant symptoms despite optimal heart failure therapy (including cardiac resynchronisation where appropriate), are judged to be at excessive risk for MV surgery by a Heart Team, fulfil the echocardiographic criteria of eligibility, and do not have existing comorbidities to preclude the benefits of correction or reduction of MR. • Ongoing trials in patients with isolated secondary MR will define whether percutaneous EE repair has a significant role in the management of heart failure. • Randomized studies are needed to clarify whether correction of MR in high-risk patients provides clinical and prognostic benefit in comparison with optimal medical therapy.