Optimization of GDMT should be under the supervision of a cardiologist expert in the treatment of patients with HF to achieve optimal results and to determine with the MDT when symptoms are truly refractory to GDMT before decisions are made for surgical or transcatheter Table 18. Stages of Secondary MR Stage Definition Valve Anatomy Valve Hemodynamics* Associated Cardiac Findings Symptoms A At risk of MR Normal valve leaflets, chords, and annulus in a patient with CAD or cardiomyopathy No MR jet or small central jet area <20% LA on Doppler Small vena contracta Normal or mildly dilated LV size with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy B Progressive MR Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets Regurgitant volume Regurgitant fraction Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction attributable to primary myocardial disease Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy C Asymptomatic severe MR Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets Regurgitant volume Regurgitant fraction Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction attributable to primary myocardial disease Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy D Symptomatic severe MR Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets Regurgitant volume Regurgitant fraction Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction attributable to primary myocardial disease HF symptoms attributable to MR persist even after revascularization and optimization of medical therapy Decreased exercise tolerance Exertional dyspnea *Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. 