Recommendations F. Recommendations on indications for mitral valve intervention in chronic severe secondary mitral regurgitation^a.

Recommendations	Classb	Levelc
Valve surgery/intervention is recommended only in patients with severe SMR who remain symptomatic despite GDMT (including CRT if indicated) and has to be decided by a structured collaborative Heart Team. 247,323,336,337	I	B
Patients with concomitant coronary artery or other cardiac disease requiring treatment
Valve surgery is recommended in patients undergoing CABG or other cardiac surgery. 329,330,333	I	B
In symptomatic patients, who are judged not appropriate for surgery by the Heart Team on the basis of their individual characteristics,d PCI (and/or TAVI) possibly followed by TEER (in case of persisting severe SMR) should be considered.	IIa	C
Patients without concomitant coronary artery or other cardiac disease requiring treatment
TEER should be considered in selected symptomatic patients, not eligible for surgery and fulfilling criteria suggesting an increased chance of responding to the treatment. 337,338,356,357 e	IIa	B
Valve surgery may be considered in symptomatic patients judged appropriate for surgery by the Heart Team.	IIb	C
In high-risk symptomatic patients not eligible for surgery and not fulfilling the criteria suggesting an increased chance of responding to TEER, the Heart Team may consider in selected cases a TEER procedure or other transcatheter valve therapy if applicable, after careful evaluation for ventricular assist device or heart transplant.e	IIb	C
2D: two-dimensional; CABG: coronary artery bypass grafting; CRT: cardiac resynchronization therapy; EROA: effective regurgitation orifice area; GDMT: guideline-directed medical therapy; LVEF: left ventricular ejection fraction; SMR: secondary mitral regurgitation; PCI: percutaneous coronary intervention; SMR: secondary mitral regurgitation; TAVI: transcatheter aortic valve implantation; TEER: transcatheter edge-to-edge repair. aSee Table 7 for SMR quantification (an EROA ≥30 mm2 by 2D proximal isovelocity surface area corresponds likely to severe SMR). Quantification of SMR must always be performed under optimal guidelines-directed medical treatment. bClass of recommendation. cLevel of evidence. dLVEF, predicted surgical risk, amount of myocardial viability, coronary anatomy/target vessels, type of concomitant procedure needed, TEER eligibility, likelihood of durable surgical repair, need of surgical mitral replacement, local expertise. eCOAPT criteria (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation): see Supplementary Table 7.