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Functional mitral regurgitation — Clinical Guidelines

Overview

Functional mitral regurgitation (FMR) is a condition characterized by the incompetence of the mitral valve due to leaflet tethering and annular dilation, often secondary to left ventricular dysfunction. 1 4

Diagnosis

Echocardiography: Essential for diagnosing FMR, assessing severity, and evaluating left ventricular function and right ventricular involvement. 1 3

Right Ventricular Function: Assessment of right ventricular ejection fraction (RVEF) using 3D echocardiography can predict outcomes. RVEF ≤45% indicates right ventricular dysfunction (RVD). 1

Mitral Valve Orifice Area (MVOA): Important for assessing risk of iatrogenic stenosis post-procedure; baseline MVOA ≥3.5 cm2 is considered. 2

Coronary Sinus (CS) Assessment: CT-based evaluation of CS distance and angle relative to the mitral annulus can predict procedural success in indirect annuloplasty. 3

Management

Transcatheter Edge-to-Edge Repair (TEER): First-line treatment for FMR, with considerations for right ventricular function and mitral valve orifice area. 1 2

Device Selection: Use of PASCAL Ace device with smaller spacers may reduce risk of MV stenosis in patients with smaller MVOA. 2

Indirect Annuloplasty: Carillon device implantation can be effective; procedural success may correlate with specific CS-annulus geometric parameters. 3

Special Populations

Right Ventricular Function: Elderly patients with FMR undergoing TEER may have higher rates of RVD, impacting survival outcomes. 1

Geometric Considerations: Specific patient anatomical features (CS-annulus relationship) may influence procedural success in indirect annuloplasty, relevant across age groups. 3

Key Recommendations

Evaluate pre-procedural right ventricular function using 3D echocardiography to predict mid-term survival outcomes in FMR patients undergoing TEER. (Evidence: Moderate) 1

Consider baseline mitral valve orifice area when selecting transcatheter devices to minimize risk of iatrogenic stenosis post-TEER. (Evidence: Moderate) 2

Utilize CT-based assessment of coronary sinus geometry relative to the mitral annulus to optimize patient selection for indirect mitral annuloplasty. (Evidence: Moderate) 3

References

1 Viva T, Zannoni J, Rubbio AP, Lupi L, Agricola E, Biagini E et al.. Evaluation of three-dimensional right ventricular function and reverse remodelling in patients undergoing percutaneous mitral valve repair for functional mitral regurgitation: insights from a multicentre Italian registry. Acta cardiologica 2026. link 2 Paukovitsch M, Felbel D, Tadic M, Keßler M, Scheffler J, Gröger M et al.. The effect of a smaller spacer in the PASCAL Ace on residual mitral valve orifice area. Clinical research in cardiology : official journal of the German Cardiac Society 2025. link 3 Rottländer D, Ballof J, Gödde M, Degen H, Ögütcü A, Alektorov K et al.. CT-Angiography to predict outcome after indirect mitral annuloplasty in patients with functional mitral regurgitation. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions 2021. link 4 Jaworek M, Mangini A, Maroncelli E, Lucherini F, Rosa R, Salurso E et al.. Ex Vivo Model of Functional Mitral Regurgitation Using Deer Hearts. Journal of cardiovascular translational research 2021. link

Functional mitral regurgitation