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Secondary mitral regurgitation: pathophysiology, proportionality and prognosis
  1. Omar Chehab1,
  2. Ross Roberts-Thomson2,
  3. Clarissa Ng Yin Ling1,
  4. Michael Marber3,
  5. Bernard D Prendergast2,
  6. Ronak Rajani4,
  7. Simon R Redwood2
  1. 1 Cardiology, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
  2. 2 Department of Cardiology, St Thomas’ Hospital, London, UK
  3. 3 Lambeth Wing, King’s College Hospital, London, UK
  4. 4 Department of Adult Echocardiography, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
  1. Correspondence to Dr Omar Chehab, Cardiology, Guy's and Saint Thomas' Hospitals NHS Trust, London SE1 9RT, UK; omar.chehab{at}


Secondary mitral regurgitation (SMR) occurs as a result of multifactorial left atrioventricular dysfunction and maleficent remodelling. It is the most common and undertreated form of mitral regurgitation (MR) and is associated with a very poor prognosis. Whether SMR is a bystander reflecting the severity of the cardiomyopathy disease process has long been the subject of debate. Studies suggest that SMR is an independent driver of prognosis in patients with an intermediate heart failure (HF) phenotype and not those with advanced HF. There is also no universal agreement regarding the quantitative thresholds defining severe SMR and indeed there are challenges with echocardiographic quantification. Until recently, no surgical or transcatheter intervention for SMR had demonstrated prognostic benefit, in contrast with HF medical therapy and cardiac resynchronisation therapy. In 2018, the first two randomised controlled trials (RCTs) of edge-to-edge transcatheter mitral valve repair versus guideline-directed medical therapy in HF (Percutaneous Repair with the MitraClip Device for Severe (MITRA-FR), Transcather mitral valve repair in patients with heart failure (COAPT)) reported contrasting yet complimentary results. Unlike in MITRA-FR, COAPT demonstrated significant prognostic benefit, largely attributed to the selection of patients with disproportionately severe MR relative to their HF phenotype. Consequently, quantifying the degree of SMR in relation to left ventricular volume may be a useful discriminator in predicting the success of transcatheter intervention. The challenge going forward is the identification and validation of such parameters while in parallel maintaining a heart-team guided holistic approach.

  • mitral regurgitation
  • secondary mitral regurgitation
  • functional mitral regurgitation
  • heart failure
  • systolic left ventricular dysfunction

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  • Contributors OC was principle author of the manuscript along with RR-T and CNYL. MM, BDP and SRR along with RR were responsible for reviewing and editing of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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