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Perspectives on Secondary Mitral Regurgitation in Heart Failure

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Abstract

Purpose of the Review

This review focuses on broader perspectives of mitral regurgitation (MR) in patients with heart failure.

Recent Findings

The ratio of regurgitant volume to end-diastolic volume appears to help identify patients who may benefit from valve interventions. Secondary MR is not only attributed to geometric changes of the LV but also related to the structural changes in the mitral valve that include fibrosis of the mitral leaflets and changes in the extracellular matrix. The transition from mild to severe secondary MR can occur at different rates, from a slow LV remodeling process to a more abrupt process precipitated by an inciting event such as atrial fibrillation. Septal flash and apical rocking, two new visual markers of LV mechanical dyssynchrony, appear to be predictive of MR reduction following cardiac resynchronization therapy. Optimal guideline-directed medical therapy has been shown to decrease the severity of secondary MR effectively.

Summary

A theoretical framework to characterize secondary MR as it relates to the onset of MR is proposed. Type A: Early onset of MR contemporaneous with myocardial injury. The maladaptive LV remodeling occurs in parallel with MR. Type B: LV remodeling proceeds without significant MR until the LV is moderately dilated, which coincides with or without inciting factors such as atrial fibrillation. Type C: LV remodeling proceeds after myocardial injury without significant MR until the LV is severely dilated. MR is a late manifestation of LV remodeling.

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Acknowledgments

We would like to acknowledge the late Dr. William H. Gaasch for his important contributions to better characterize and frame secondary MR in terms of volumetric data. He had a significant impact on our collective understanding of secondary MR. The editors would like to thank Dr. Mathew Lee for taking the time to handle the review of this manuscript.

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  1. Division of Cardiology, University of Massachusetts Chan Medical School, UMassMemorial Medical Center, Worcester, MA, USA

    Theo E. Meyer, Kai Chen, Matthew W. Parker, Jeff Shih & Youssef Rahban

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Meyer, T.E., Chen, K., Parker, M.W. et al. Perspectives on Secondary Mitral Regurgitation in Heart Failure. Curr Heart Fail Rep 20, 417–428 (2023). https://doi.org/10.1007/s11897-023-00627-9

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