Case: Severe secondary MR despite optimized GDMT — when TEER enters the discussion
A 76-year-old with HFrEF, recurrent HF hospitalizations, and severe ventricular functional MR remains symptomatic despite optimized GDMT. LVEF 32%, EROA 0.42 cm², LVESD 62 mm. What should the Intervention Navigator return, and when does TEER become a reasonable option?
Clinical scenario
76-year-old woman, HFrEF LVEF 32%, NYHA Class III dyspnea despite 6 months of optimized GDMT: sacubitril/valsartan 97/103 mg twice daily, carvedilol 25 mg twice daily, eplerenone 25 mg daily, empagliflozin 10 mg daily, and furosemide 40 mg twice daily. Two HF hospitalizations in the past year. TTE: ventricular functional MR, qualitative severe, EROA 0.42 cm², regurgitant volume 64 mL/beat, regurgitant fraction 50%, LVEF 32%, LVESD 62 mm, LVEDD 70 mm, PASP 52 mmHg. STS predicted mortality 8.2%. No CRT indication: narrow QRS and no clear dyssynchrony.
Severe secondary MR persists despite optimized HF therapy. Is TEER an option, and what must be confirmed first?
Meeting the key clinical criteria
This patient meets the core clinical profile for TEER consideration in secondary MR.
MR is severe by ACC/AHA quantitative range: EROA 0.42 cm² and regurgitant volume 64 mL/beat.
LVEF is within the COAPT-like range of 20–50%. LVESD is ≤70 mm at 62 mm. PASP is ≤70 mmHg at 52 mmHg.
She remains symptomatic despite 6 months of optimized GDMT and has recurrent HF hospitalizations.
These findings fit a COAPT-like clinical profile.
But this does not mean TEER is already indicated. It means Heart Valve Team evaluation is appropriate.
TEER eligibility requires anatomy confirmation
Clinical and numeric criteria are necessary, but not sufficient.
TEER planning requires dedicated TEE assessment of mitral anatomy. Key features include leaflet morphology, coaptation gap, coaptation depth, posterior leaflet length, calcification at the grasping zone, mitral valve area, transmitral gradient, commissural involvement, clefts, and severe MAC.
What does 'TEER may be reasonable' actually mean?
When the Intervention Navigator returns 'TEER may be reasonable,' it does not mean TEER is indicated. It means the patient should be referred for Heart Valve Team evaluation and TEE anatomy confirmation. The final decision requires integrating anatomy, surgical risk, HF trajectory, expected benefit, and patient goals.
What TEER can offer in this patient
In COAPT, TEER added to maximally tolerated GDMT significantly reduced HF hospitalizations and mortality in carefully selected patients with symptomatic HFrEF and severe secondary MR. This patient has a similar clinical profile: persistent symptoms, recurrent HF hospitalizations, severe secondary MR, LVEF 32%, LVESD 62 mm, and PASP 52 mmHg despite optimized therapy.
If anatomy is suitable, TEER may offer symptom improvement and reduced HF hospitalization risk.
However, TEER does not cure the cardiomyopathy. LVEF may not normalize. The goal is to reduce the additional MR-related burden and improve symptoms and HF trajectory.
Next step
Referral to a Heart Valve Team is the appropriate next step. The team should include interventional cardiology, cardiac surgery, HF cardiology, and imaging expertise.
The Heart Valve Team will assess anatomy by TEE, confirm feasibility, weigh procedural risk against expected benefit, and discuss patient goals.
The STS predicted mortality of 8.2% suggests high surgical risk. If anatomy is suitable, TEER becomes a strong option, while the role of surgery should still be considered by the team.
Perioperative implication
If this patient presents before elective noncardiac surgery, the perioperative team should recognize that severe secondary MR and HFrEF remain active issues and that TEER evaluation is appropriate.
LVEF 32%, PASP 52 mmHg, and recurrent HF hospitalizations are important perioperative risk markers, especially for surgery with major hemodynamic stress.
For elective surgery, consider whether Heart Valve Team assessment and possible TEER evaluation should occur before proceeding, depending on the urgency and invasiveness of the planned procedure.
For urgent or time-sensitive surgery, plan around the known HFrEF and severe MR: invasive monitoring, vasoactive/inotrope strategy, careful fluid management, and postoperative critical care planning.
What is the most appropriate next step?
- 1.Refer to the Heart Valve Team for TEE anatomy assessment and TEER evaluation✓ Recommended
Correct. Severe secondary MR criteria are met, GDMT is optimized, and the patient remains symptomatic with recurrent HF hospitalizations. The next step is not automatic TEER, but Heart Valve Team evaluation and anatomic confirmation.
- 2.Continue current GDMT and repeat echo in 3 months△ Consider
Consider only if there is uncertainty about medication optimization, adherence, or volume status. GDMT already appears optimized for 6 months, and the patient has recurrent HF hospitalizations. Further watchful waiting alone is less compelling than Heart Valve Team evaluation.
- 3.Refer directly for surgical mitral annuloplasty⚠ Not recommended
Not the first pathway. This patient has high surgical risk and a COAPT-like clinical profile. If anatomy is suitable, TEER is a strong option. Surgery may still be discussed by the Heart Valve Team, but direct surgical referral is not the primary next step.
Teaching points
- TEER in secondary MR is for selected patients — optimized GDMT, persistent symptoms, severe secondary MR, LVEF 20–50%, LVESD ≤70 mm, PASP ≤70 mmHg, and suitable anatomy are all required.
- This patient fits a COAPT-like clinical profile — the evidence base that supports TEER in carefully selected secondary MR patients.
- 'TEER may be reasonable' means Heart Valve Team referral and TEE anatomy confirmation, not automatic TEER indication.
- TEER does not cure the cardiomyopathy — the goal is to reduce MR-related burden and improve symptoms and HF outcomes; LVEF may not normalize.
- Heart Valve Team evaluation integrates anatomy, surgical risk, HF trajectory, expected benefit, and patient goals.
Apply this in practice
Use the Secondary MR Intervention Navigator to evaluate the full decision pathway.
Secondary MR Intervention Navigator