Functional Mitral Regurgitation in Heart Failure: Analysis of the ESC Multidisciplinary Heart-Team Position Statement and Review of Current Guidelines

Abstract

FUNCTIONAL OR SECONDARY mitral regurgitation (FMR) is defined as mitral valve incompetence from adverse changes in left ventricular (LV) size, shape, or function, which may or may not be associated with annular dilatation. 1 Bonow RO O'Gara PT Adams DH et al. 2020 focused update of the 2017 ACC Expert Consensus Decision Pathway on the management of mitral regurgitation: A report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020; 75: 2236-2270 Crossref PubMed Scopus (67) Google Scholar FMR commonly is seen in patients with both ischemic cardiomyopathy and nonischemic cardiomyopathy and may contribute to patient symptoms and clinical deterioration in patients with heart failure (HF). Management of patients with FMR in HF can be challenging—not only does mortality increase in patients with HF with FMR, patient mortality also is related directly with increasing severity of the degree of MR. 2 Koelling TM Aaronson KD Cody RJ et al. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J. 2002; 144: 524-529 Crossref PubMed Scopus (386) Google Scholar The recently published European Society of Cardiology (ESC) guidelines for the management of FMR in HF serves to highlight the importance of a thoughtful and comprehensive approach to caring for these patients. 3 Coats AJS Anker SD Baumbach A et al. The management of secondary mitral regurgitation in patients with heart failure: A joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC. Eur Heart J. 2021; 42: 1254-1269 Google Scholar Given the considerable complexity of this clinical entity, multidisciplinary treatment planning via the “Heart-Team” model represents a logical choice from which to begin care planning. The Heart Team is a multidisciplinary specialty physician group that aims to offer patients an optimized, unified plan of care to treat this complex cardiac condition. The value of this collaborative approach already has been reported across a spectrum of mitral valve disease care. 4 Heuts S Olsthoorn JR Hermans SMM et al. Multidisciplinary decision-making in mitral valve disease: The mitral valve heart team. Neth Heart J. 2019; 27: 176-184 Crossref PubMed Scopus (8) Google Scholar Within this manuscript, the authors describe the available data on patients with FMR in HF, summarize the diagnostic criteria for FMR and imaging modalities available for diagnosis, and highlight the contemporary management of FMR in HF (with a focused review of the two sentinel trials in transcatheter mitral interventions).