Mitral regurgitation surgery indications: Difference between revisions

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❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite GDMT or [[CRT]]<br>
❑ [[Valve]] [[surgery]]/intervention is recommended in [[symptomatic]] severe secondary [[MR]] despite [[medical therapy]] or [[CRT]]<br>
❑Valve surgery is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]]<br>
❑[[Valve]] [[surgery]] is recommended in [[patients]] undergoing [[CABG]] or other [[cardiac]] [[surgery]]<br>
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|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''

Revision as of 11:18, 10 June 2022



Intern
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Vasodilator therapy with ACE inhibitors and hydralazine is the mainstay of therapy in patient with chronic compensated mitral regurgitation. Acute mitral regurgitation requires urgent mitral valve repair or mitral valve replacement. MV surgery is indicated in patients with chronic aortic regurgitation who develop symptomatic mitral valve regurgitation. It is also indicated in patients with abnormalities in LV size or function (These include a left ventricular ejection fraction (LVEF) of less than 60% and a left ventricular end systolic dimension (LVESD) of greater than 45 mm), pulmonary hypertension, or new onset atrial fibrillation even without symptoms [1]. The patient with severe LV dysfunction (an LVEF < 30% and/or a left ventricular end-systolic dimension greater than 55 mm) poses a higher risk but may undergo surgery if chordal preservation is likely. MV repair is recommended over MV replacement in the majority of patients with severe chronic MR who require surgery, and patients should be referred to surgical centers experienced in MV repair.

Medical Therapy of Chronic Mitral Regurgitation

Vasodilator therapy is a mainstay of medical therapy in the management of chronic mitral regurgitation. In the chronic state, the most commonly used agents are ACE inhibitors and hydralazine. Studies have shown that the use of ACE inhibitors and hydralazine can delay surgical treatment of mitral regurgitation[2] [3].

Surgical Therapy for Chronic Mitral Regurgitation

Recommendations for intervention in primary mitral regurgitation
(Class I, Level of Evidence B):

Mitral valve repair is considered when the results of surgical technique are expected to be durable
Surgery is recommended in low risk symptomatic patients
Surgery is recommended in asymptomatic patients with LV dysfunction (LVESD ≥ 40 mm and/or LVEF ≤ 60%)

(Class IIa, Level of Evidence B):

Surgery is recommended in asymptomatic patients with preserved LV function (LVESD <40 mm and LVEF >60%) and AF secondary to mitral regurgitation or pulmonary hypertension (SPAP at rest >50 mmHg)
Surgical mitral valve repair is recommended in low-risk asymptomatic patients with LVEF > 60%, LVESD <40 mmd and significant LA dilatation (volume index ≥60 mL/m2 or diameter ≥55 mm)

(Class IIb, Level of Evidence B) :

TEER may be considered in symptomatic patients who are inoperable due to high surgical risk, with echocardiographic criteria of eligibility

Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;


The above table adopted from 2021 ESC Guideline[4]



 
 
 
Management of patients with chronic severe secondary mitral regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Symptomatic despite medical therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*Optimazing medical therapy
  • CRT implantation if indicated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe comorbidities or life expectancy < 1 year
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Palliative care
 
 
 
 
Presence of CAD or other cardiac disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Appropriate for surgery
 
Persisting severe symptomatic secondary MR
 
Valve surgery if fulfilling criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CABG, MV surgery
 
PCI, TAVI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persisting severe symptomatic secondary MR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
NO
  • Close follow-up
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • End-stage LV, RV failure
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Fulfilling criteria suggesting an increased chance of responding to TEER
  •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    NO
  • Heart transplantation, left ventricular assist devices palliative care, TEER in selected cases or other transcatheter valve therapy if applicable for symptoms improvement
  •  
     
     
     
    The above algorithm adopted from 2021 ESC Guideline[4]


    Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; MV:Mitral valve ; PCI:Percutaneous coronary intervention; LVAD: Left ventricular assist devices; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation; CAD: Coronary artery disease

    Recommendations for intervention in chronic severe secondary mitral regurgitation
    (Class I, Level of Evidence B):

    Valve surgery/intervention is recommended in symptomatic severe secondary MR despite medical therapy or CRT
    Valve surgery is recommended in patients undergoing CABG or other cardiac surgery

    (Class IIa, Level of Evidence B):

    TEER should be considered in selected symptomatic patients, not suitable for surgery and high likelihood of responding to TEER

    (Class IIa, Level of Evidence C):

    ❑ In symptomatic inoperable patients, PCI (and/orTAVI) possibly followed by TEER (in case of persisting severe secondary MR) should be considered

    (Class IIb, Level of Evidence C) :

    Valve surgery may be considered in symptomatic patients who are appropriate for surgery
    ❑In high-risk symptomatic patients not eligible for surgery and low likelihood of responding to TEER, making decision about TEER procedure or other transcatheter valve therapy and evaluation for ventricular assist device or heart transplant should be considered

    The above table adopted from 2021 ESC Guideline[4]


    Abbreviations: CABG: Coronary artery bypass grafting; CRT: Cardiac resynchronization therapy; LV: Left ventricle; ERO:Effective regurgitation orifice area ; PCI:Percutaneous coronary intervention; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair; TAVI: Transcatheter aortic valve implantation


     
     
     
    Management of patients with severe chronic primary mitral regurgitation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Symptoms
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
     
     
     
     
     
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Determining the risk of surgery
     
     
     
     
     
     
     
     
     
     
    LVEF ≤ 60% or LVESD ≥ 40 mm
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    High risk of futility
     
     
    High risk for surgery or inoperable
     
     
     
     
    Yes
     
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
     
    NO
     
     
    Surgery
     
     
     
    New onset AF or SPAP>50 mmHg
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    TEER if anatomically suitable, optimal heart failure therapy
     
     
    Surgery (repair whenever possible)
     
     
     
     
    Yes, surgery
     
    NO
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    High likelihood of durable repair, low surgical risk, and LA dilatation
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    NO
     
    Yes
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Follow-up
     
    Surgical mitral valve repair
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

    Abbreviations: AF: Atrial fibrillation; LA: Left atrial; LV: Left ventricle; LVESD:Left ventricular end systolic diameter ; SPAP:Systolic pulmonary arterial pressure; LVEF: Left ventricular ejection fraction; TEER: Transcatheter edge to edge repair;


    The above algorithm adopted from 2021 ESC Guideline[4]











    There are two surgical options for the treatment of mitral regurgitation: mitral valve replacement and mitral valve repair. In general, mitral valve repair is preferred to mitral valve replacement as it carries a lower risk of subsequent prosthetic valve endocarditis and results in better preservation of left ventricular function.

    Scenarios Favoring Mitral Valve Repair

    Scenarios Favoring Mitral Valve Replacement

    • Extensive calcification or degeneration of a leaflet or annulus
    • Prolapse of more than one-third of the leaflet tissue
    • Extensive chordal fusion, calcification, or papillary muscle rupture
    • Extensive damage of mitral valve secondary to endocarditis

    Sources

    • 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [1]

    References

    1. 1.0 1.1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
    2. Greenberg BH, Massie BM, Brundage BH, Botvinick EH, Parmley WW, Chatterjee K (1978). "Beneficial effects of hydralazine in severe mitral regurgitation". Circulation. 58 (2): 273–9. PMID 668075. Retrieved 2011-03-16. Unknown parameter |month= ignored (help)
    3. Hoit BD (1991). "Medical treatment of valvular heart disease". Current Opinion in Cardiology. 6 (2): 207–11. PMID 10149580. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
    4. 4.0 4.1 4.2 4.3 Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis M, De Paulis R, Delgado V, Freemantle N, Gilard M, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W (February 2022). "2021 ESC/EACTS Guidelines for the management of valvular heart disease". Eur Heart J. 43 (7): 561–632. doi:10.1093/eurheartj/ehab395. PMID 34453165 Check |pmid= value (help).
    5. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.
    6. Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE (2000). "Mitral valve repair and replacement for rheumatic disease". J Thorac Cardiovasc Surg. 119 (1): 53–60. PMID 10612761.
    7. Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M (2001). "Very long-term survival and durability of mitral valve repair for mitral valve prolapse". Circulation. 104 (12 Suppl 1): I1–I7. PMID 11568020.
    8. Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R; et al. (2003). "Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease". J Thorac Cardiovasc Surg. 125 (6): 1350–62. PMID 12830055.

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