Table 4.1. Recommendations for percutaneous interventions in severe secondary mitral insufficiency.

Recommendations	Class	LE	Comments	Table 2018	Ref.
Percutaneous mitral valve clipping
Ischemic or dilated
Refractory symptoms (NYHA II-IV), despite guideline-directed medical therapy and after Heart Team evaluation.	IIa	B	NEW: Recommendation supported by a randomized trial with mortality endpoint.	Item 11.3 (page 467)	36
We recommend optimization of guideline-directed medical therapy (GDMT), including cardiac resynchronization therapy and revascularization, when appropriate, before considering percutaneous mitral insufficiency (MI) treatment for patients with HFrEF and severe MI. The COAPT (Transcatheter Mitral-Valve Repair in Patients with Heart Failure) trial assessed whether the edge-to-edge device might benefit patients with moderately severe or severe secondary MI (EROA greater than or equal to 30 mm2 and/or regurgitation volume greater than 45 mL) with LVEF 20 to 50%, LV end-systolic diameter smaller than 7 cm and persistent symptoms, despite maximized evidence-based therapy.36 The 2020 Valve Disease Guidelines overlooks this distinction when selecting patients. In order to maintain linearity between the Guidelines, it remains as established in the 2020 Valve Disease Guidelines.37

HF: heart failure; HFrEF: heart failure with reduced ejection fraction; LV: left ventricle; LVEF: left ventricular ejection fraction; MI: mitral insufficiency.