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TEER for Secondary MR - COAPT Criteria — EECC MCQ

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HardValvular Heart DiseaseTEER for Secondary MR - COAPT CriteriaEECC

A 70-year-old man with severe secondary mitral regurgitation and HFrEF (LVEF 32%) has persistent NYHA class III symptoms despite optimal GDMT. CMR confirms large inferior MI scar. Echocardiography shows an EROA of 0.30 cm² and regurgitant volume of 45 mL. The Heart Team considers TEER (MitraClip). What is the key echocardiographic criterion that identifies patients most likely to benefit from TEER in secondary MR based on the COAPT trial?

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Correct answer: D — Severe secondary MR (EROA ≥0.30 cm²) that is disproportionate to the degree of LV dilatation (LVEDV <96 mL/m²)

The COAPT-responsive phenotype in ventricular/secondary mitral regurgitation is severe MR that is large relative to the amount of LV dilatation: a “disproportionate” MR pattern. In exam terms this is severe secondary MR with EROA ≥0.30 cm² and regurgitant volume around ≥45 mL, with the LV not excessively dilated; LVEDVi <96 mL/m² is the commonly tested COAPT-derived discriminator. This patient’s EROA 0.30 cm² and regurgitant volume 45 mL meet severe secondary MR thresholds, and the key selection issue is whether MR is disproportionate to LV size. EROA ≥0.40 cm² alone is too restrictive for secondary MR, “any” secondary MR is incorrect, and severe TR, LV aneurysm or scar burden do not define the echocardiographic subgroup most likely to benefit from TEER.

Reference: 2025 ESC/EACTS Guidelines for the management of valvular heart disease, European Heart Journal 2025; section on secondary mitral regurgitation and TEER: https://academic.oup.com/eurheartj/article/46/44/4635/8234488