Diagnosis of Chronic Secondary MR Recommendations for Diagnosis of Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 31. COR LOE Recommendations In patients with chronic secondary MR (Stages B to D), TTE is useful to establish the etiology and to assess the extent of regional and global LV remodeling and systolic dysfunction, severity of MR, and magnitude of pulmonary In patients with chronic secondary MR (Stages B to D), noninvasive imaging (stress nuclear/ PET, CMR, or stress echocardiography), coronary CT angiography, or coronary arteriography is useful to establish etiology of MR and to assess myocardial viability. In patients with chronic secondary MR with severe symptoms (Stage D) that are unresponsive to GDMT who are being considered for transcatheter mitral valve interventions, TEE is indicated to determine suitability for the procedure.3 8 In patients with chronic secondary MR undergoing transcatheter mitral valve intervention, intraprocedural guidance with TEE is recommended.4,7,9 13 Synopsis In symptomatic patients with chronic secondary MR, TTE is the initial diagnostic modality. Assessment of the coro- nary anatomy and myocardial viability may be helpful in management if ischemic MR is suspected. If transcatheter mitral valve intervention is contemplated, TEE determines suitability for the procedure and guides the procedure.1 Recommendation-Specific Supportive Text 1. TTE is essential in patients with MR to identify patients with primary MR and those with sec- ondary forms of MR. In general, in patients with LV systolic dysfunction and symptoms of HF, the presence of chronic secondary MR of any sever- ity is associated with a worse prognosis than that seen in the absence of MR. 