IMR Press / RCM / Volume 23 / Issue 3 / DOI: 10.31083/j.rcm2303088
Open Access Review
Learning from Controversy and Revisiting the Randomized Trials of Secondary Mitral Regurgitation
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1 Department of Cardiac Surgery, University Hospitals Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
2 Sapienza University of Rome, 00185 Rome, Italy
3 Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Clydebank G81 4DY Glasgow, UK
4 Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
*Correspondence: (Francesco Nappi)
Academic Editors: Francesco Onorati and Antonio Mangieri
Rev. Cardiovasc. Med. 2022, 23(3), 88;
Submitted: 10 November 2021 | Revised: 25 January 2022 | Accepted: 10 February 2022 | Published: 4 March 2022
(This article belongs to the Special Issue The treatment of mitral regurgitation in the 21st Century)
Copyright: © 2022 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license.

Until recently, conventional mitral valve surgery has been the treatment of choice even in secondary mitral regurgitation. Recent evidence, however, advocates the use of transcatheter edge-to-edge mitral valve repair (TEER) of the mitral valve. This has been reflected by the change in guidelines of the American College of Cardiology/American Heart Association. We reviewed the literature to shed light on the risks and benefits of all interventions, surgical, transcatheter and guideline-directed medical therapy. Secondary mitral regurgitation occurs due to an imbalance between closing forces and tethering forces. Given the pathology extends beyond the valve alone, treatment should be directed at restoring the geometrical shape of the left ventricle alongside the valve. Myocardial revascularization plays a pivotal role in preventing recurrence. The role of papillary muscle approximation in addition to restrictive mitral annuloplasty should be considered in a select group of patients. We also reviewed the current literature on TEERs from the COAPT and Mitra-FR trials while highlighting the concept of proportionate/disproportionate MR which may help identify which patients benefit from mitral valve restoration. Treatment of this condition will require robust randomized trials alongside the use of state-of-the-art imaging technologies available with the full complement of the multidisciplinary team to ensure the best outcomes for each patient.

secondary mitral regurgitation
mitral valve replacement
mitral valve repair
subannular repair
transcatheter edge to edge repair
Fig. 1.
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