Mitral Regurgitation in Contemporary Practice: From Diagnosis to Management

Abstract

Mitral regurgitation (MR) is the most prevalent valvular heart disease in developed countries, affecting approximately 1 in 50 individuals in the general population and about 1 in 10 individuals older than 75 years. Despite its frequency, MR remains a complex clinical challenge due to its heterogeneous etiology, variable natural history, and evolving therapeutic landscape. The 2025 ESC/EACTS guidelines have introduced a paradigm shift, transitioning from a purely morphological classification to a mechanism-based framework that distinguishes primary, ventricular secondary, and atrial secondary MR. This review provides a comprehensive overview of contemporary MR management. We discuss the updated classification system and the associated implications for risk stratification, emphasizing how the underlying mechanism of MR influences prognosis and guides treatment selection. The diagnostics section addresses multimodality imaging strategies, detailing the complementary roles of echocardiography, cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT) in assessing severity, characterizing anatomy, and planning interventions. The management section addresses optimization of medical therapy, surgical techniques (repair versus replacement, including conventional and minimally invasive approaches), and transcatheter interventions, with particular focus on mitral transcatheter edge-to-edge repair (M-TEER) and emerging transcatheter mitral valve replacement technologies. We propose an integrated, stepwise management algorithm that incorporates early risk markers, including natriuretic peptides, to guide the timing of intervention before irreversible myocardial damage occurs. The critical role of multidisciplinary heart valve teams (HVTs) in individualizing treatment decisions is highlighted throughout. Early recognition of MR and timely intervention are paramount to prevent progression to irreversible left ventricular dysfunction and heart failure. The mechanism-based classification enables more precise patient phenotyping and treatment tailoring. Transcatheter therapies have expanded therapeutic options for high-risk surgical patients, although careful patient selection remains essential. Natriuretic peptides have emerged as valuable biomarkers for identifying candidates who may benefit from earlier intervention. Contemporary MR management requires the integration of advanced imaging, mechanism-based classification, and collaborative decision-making within HVTs. As therapeutic options continue to expand, optimal outcomes depend on matching the right intervention to the right patient at the right time.