ESC / EACTS · 2025

Mitral Regurgitation — Management Guideline

Source: 2025 ESC/EACTS Guidelines for the management of valvular heart disease, European Heart Journal

✓ Edition checked 3 Oct 2026 — ESC / EACTS 2025 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Mitral regurgitation is graded by integrating echocardiographic quantification, valve anatomy, and the consequences on the left ventricle, left atrium, pulmonary pressure, and right heart, with CMR used when echocardiography is inconclusive. Mechanism comes first: primary (degenerative or structural valve disease) versus secondary (functional) regurgitation, and in secondary disease an atrial phenotype versus a ventricular phenotype. Symptoms are exertional dyspnoea and reduced exercise tolerance; many patients are asymptomatic and need surveillance because the timing of surgery is now guided by LV and atrial markers rather than symptoms alone.

⚠ Alarm features (investigate before diagnosing)

New or worsening dyspnoea, or signs of heart failure
New atrial fibrillation
Rising pulmonary artery pressure
LVEF at or below 60% or LV end-systolic diameter reaching 40 mm in a patient with severe primary regurgitation
Acute severe regurgitation (for example from chordal rupture or papillary muscle dysfunction)

Initial workup

Test	When to order
Transthoracic echocardiography	Initial diagnosis and surveillance: severity, mechanism, LVEF, LV end-systolic diameter (and indexed value), left atrial volume index, and estimated pulmonary pressure.
Multimodality imaging including CMR	When echocardiographic grading is inconclusive or discordant; the EACVI/ESC position paper on native valvular regurgitation integrates CMR and recommends a multimodality approach.
Transoesophageal echocardiography	To define the mechanism and the feasibility of repair before intervention (general clinical knowledge, not verified in the 2025 text).
Heart Team and Heart Valve Centre assessment	Before any intervention, to weigh repair feasibility, surgical risk, and the choice between surgery and transcatheter repair.

Decision Points

❓ What is the mechanism of the mitral regurgitation?

Primary (degenerative) severe regurgitation → Primary (degenerative) severe mitral regurgitation

Ventricular secondary regurgitation (LVEF below 50%) → Ventricular secondary mitral regurgitation (LVEF below 50%)

Atrial secondary regurgitation (for example with atrial fibrillation) → Atrial secondary mitral regurgitation

Treatment

Primary (degenerative) severe mitral regurgitation

1 Mitral valve repair surgery, with repair preferred over replacement when a durable result is expected Guideline recommendation — repair is the gold standard for chronic severe primary regurgitation when durable results are anticipated; the indication in symptomatic patients was not seen in the texts reviewed and follows prior ESC guidance (general clinical knowledge)

Dose: —
Duration: Elective, in a Heart Valve Centre
Evidence level: High
Avoid if: Repair not feasible (replacement is then considered); prohibitive surgical risk
If no response ClinicoQ pathway: If surgical risk is high, consider TEER

2 Surgical repair in asymptomatic severe primary regurgitation with LV dysfunction Strong (Guideline recommendation) — new Class I recommendation for early repair in asymptomatic patients (Class I, level B)

Dose: Triggers: LVEF 60% or below, or LVESD 40 mm or above, or indexed LVESD 20 mm/m2 or above
Duration: Elective
Evidence level: High
Avoid if: Repair not feasible; high surgical risk

3 Surgical repair in asymptomatic patients without LV dysfunction who are at low surgical risk Guideline recommendation — Class I, level B with at least three criteria; considered (Class IIa, level B) with one of the first three criteria, provided surgical risk is low, surgery is performed in a Heart Valve Centre, and a durable repair is likely

Dose: Repair if at least three of: atrial fibrillation, resting systolic pulmonary pressure above 50 mmHg, LAVI 60 mL/m2 or above (or left atrial diameter 55 mm or above), moderate or severe secondary tricuspid regurgitation. Consider surgery if secondary atrial fibrillation, systolic pulmonary pressure above 50 mmHg, or LAVI 60 mL/m2 or above is present
Duration: Elective
Evidence level: Moderate
Avoid if: High surgical risk; low likelihood of durable repair

4 Transcatheter edge-to-edge repair (TEER) in patients at high surgical risk Guideline recommendation (Class IIa, level B) — upgraded in 2025 for high-risk patients

Dose: —
Duration: Procedure
Evidence level: Moderate
Avoid if: Anatomy unsuitable for TEER

5 Concomitant tricuspid repair during left-sided valve surgery Guideline recommendation (should be considered) — for mild secondary tricuspid regurgitation with a dilated annulus (40 mm or above, or above 21 mm/m2)

Dose: —
Duration: At the time of surgery
Evidence level: Low
Avoid if: —

Ventricular secondary mitral regurgitation (LVEF below 50%)

1 Guideline-directed heart failure therapy and CRT when indicated Guideline recommendation — interventional therapy is considered when symptoms persist despite optimal medical therapy and CRT

Dose: See the heart failure pathway for foundational therapy
Duration: Before any interventional decision
Evidence level: High
Avoid if: —
If no response: If severe regurgitation and symptoms persist, evaluate for TEER

2 Transcatheter edge-to-edge repair (TEER) Strong (Guideline recommendation) — Class I, level A in haemodynamically stable symptomatic patients with LVEF below 50% and persistent severe regurgitation despite guideline-directed medical therapy and CRT, fulfilling strict selection criteria, to reduce heart failure hospitalizations and improve quality of life

Dose: —
Duration: Procedure
Evidence level: High
Avoid if: Haemodynamic instability; patients not meeting the selection criteria
If no response: Mitral surgery may be considered in concomitant complex coronary disease or when TEER is not suitable

3 Mitral surgery in selected patients Guideline recommendation (may be considered) — concomitant complex coronary artery disease, or patients not suitable for TEER

Dose: —
Duration: Per surgical indication
Evidence level: Low
Avoid if: High surgical risk

Atrial secondary mitral regurgitation

1 Surgery for atrial secondary mitral regurgitation Guideline recommendation (Class IIa) — new in 2025

Dose: —
Duration: Per surgical indication
Evidence level: Moderate
Avoid if: High surgical risk
If no response: A transcatheter procedure may be considered (Class IIb)

2 Transcatheter treatment for atrial secondary mitral regurgitation Guideline recommendation (Class IIb) — new in 2025

Dose: —
Duration: Procedure
Evidence level: Low
Avoid if: —

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.