CLINICAL STATEMENTS AND GUIDELINES Recommendations for Intervention for Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 31. COR LOE Recommendations In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent symptoms (NYHA class II, III, or IV) while on optimal GDMT for HF (Stage D), TEER is reasonable in patients with appropriate anatomy as defined on TEE and with LVEF between 20% and 50%, LVESD 70 mm, and pulmonary artery systolic pressure In patients with severe secondary MR (Stages C and D), mitral valve surgery is reasonable when CABG is undertaken for the treatment of myocardial ischemia.9 15 In patients with chronic severe secondary MR from atrial annular dilation with preserved LV systolic function (LVEF 50%) who have severe persistent symptoms (NYHA class III or IV) despite therapy for HF and therapy for associated AF or other comorbidities (Stage D), mitral valve surgery may be considered.16 20 In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent severe symptoms (NYHA class III or IV) while on optimal GDMT for HF (Stage D), mitral valve surgery may be In patients with CAD and chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) (Stage D) who are undergoing mitral valve surgery because of severe symptoms (NYHA class III or IV) that persist despite GDMT for HF, chordal-sparing mitral valve replacement may be reasonable to choose over downsized annuloplasty Synopsis Mitral TEER is indicated to improve symptoms and pro- long life in a select subset of patients with chronic se- vere secondary MR, LV systolic dysfunction, and persis- tent severe symptoms while on optimal GDMT. Surgery may improve symptoms in these patients, with mitral valve replacement preferred over repair. 