Comparison of key guidelines for management of moderate/borderline ischemic mitral regurgitation (ESC/EACTS 2025 vs ACC/AHA 2020).
| Aspect | ESC/EACTS 2025 | ACC/AHA 2020 |
|---|---|---|
| Diagnosis | ||
| TTE | IMR assessment should be performed after optimization of medical therapy and in a euvolemic and normotensive state | In patients with chronic secondary MR (stages B to D), TTE is useful to establish the etiology and to assess the extent of regional and global LV remodeling and systolic dysfunction, severity of MR, and magnitude of pulmonary hypertension |
| - | Class I, Level B-NR | |
| Other diagnostic methods | Cardiac magnetic resonance is used to confirm IMR severity and assess cardiac chamber function and dimensions, and to determine the extent of myocardial fibrosis. Owing to the dynamic nature of IMR, stress echocardiography may help to identify patients with severe IMR when values at rest are inconclusive | In patients with chronic secondary MR (stages B to D), noninvasive imaging (stress nuclear PET, CMR, or stress echocardiography), coronary CT angiography, or coronary arteriography is useful to establish etiology of MR and to assess myocardial viability |
| - | Class I, level C-EO | |
| Surgical correction | ||
| Moderate IMR during CABG | May be considered | May be reasonable |
| Class IIb, Level B | Class IIb, level B-R | |
| Preferred technique | Restrictive annuloplasty | Annuloplasty (chordal-sparing) |
| Class I, Level B | Class I, Level B-R | |
| Criteria for intervention | EROA ≥ 40 mm2, RVol ≥ 60 mL (acknowledges significance of EROA ≥ 30 mm2) + clinical/ECHO symptoms or LVESD ≤ 70 mm, LVEF 20–50% | EROA ≥ 40 mm2, RVol ≥ 60 mL, RF ≥ 50% |
| Transcatheter ‘edge-to-edge’ repair (TEER) | ||
| Indications for moderate/borderline IMR | Not recommended for isolated moderate IMR | No specific indications for moderate IMR |
| - | - | |
| Indications for severe secondary MR | Symptomatic severe secondary MR with impaired LVEF (< 50%), and persistent severe ventricular SMR, despite optimized GDMT and CRT, inoperable/high risk, COAPT criteria | Symptomatic severe secondary MR, high surgical risk, COAPT criteria |
| Class I, Level A | Class IIa, Level B-R | |
| Selection criteria | EROA ≥ 30 mm2, LVEF 20–50%, LVESD < 70 mm, optimal GDMT | EROA ≥ 40 mm2, LVEF 20–50%, LVESD < 70 mm, sPAP ≤ 70mmHg, COAPT eligibility |
| Medical therapy | ||
| Guideline-directed medical therapy (GDMT) for HF | Mandatory for all patients with secondary MR | Mandatory for all patients with secondary MR |
| Class I, Level A | Class I, Level A | |
| Components of therapy | ACEi/ARNI, BB, MRA, SGLT2i, diuretics | ACEi/ARNI, BB, MRA, SGLT2i, diuretics |
| Class I, Level A | Class I, Level A | |
| CRT if indicated | Recommended if criteria met (LBBB, QRS ≥ 150 ms, LVEF ≤ 35%) | Recommended if criteria met |
| Class I, Level A | Class I, Level A | |
| Role of medical therapy in moderate IMR | First-line treatment; may be sufficient if LV reverse remodeling occurs | First-line treatment; reassessment of MR before intervention |
| - | - | |
| Follow-up | ||
| Frequency | Echo every 3–6–12 months (according to the HF stage) or with symptom worsening | Echo every 6–12 months |
| - | - | |
IMR: ischemic mitral regurgitation; CABG: coronary artery bypass grafting; EROA: effective regurgitant orifice area; RVol: regurgitant volume; LV: left ventricle; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; GDMT: guideline-directed medical therapy; ACEi: ACE inhibitors; ARNI: angiotensin receptor-neprilysin inhibitor; BB: beta-blockers; MRA: mineralocorticoid receptor antagonists; SGLT2i: SGLT2 inhibitors; CRT: cardiac resynchronization therapy; LBBB: left bundle branch block; HF: heart failure.