Mitral regurgitation surgery indications: Difference between revisions

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{{Mitral regurgitation surgery}}
{{Mitral regurgitation surgery}}
{{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
{{CMG}}; '''Associate Editor-In-Chief:''' {{Sara.Zand}} {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
{{SK}} MR; Mitral regurgitation; LV; Left ventricle; LVESD; Left ventricular end systolic diameter; LVEF; Left ventricular ejection fraction; CABG; Coronary artery bypass grafting
==Overview==
Chronic secondary [[MR]] is associated with impaired prognosis and its management includes [[electrophysiological]], [[transcatheter]], and [[surgical interventions]]. [[Mitral valve surgery]] is recommended in [[patients]] with severe secondary [[MR]] undergoing [[CABG]] or other [[cardiac surgery]]. Decision of surgical approach should be individualized based on the [[patient]] [[characteristics]]. In selected [[patients]] without advanced [[LV remodelling]], [[mitral valve repair]] resulted in improvement in [[symptoms]], and reverse [[LV remodeling]]. [[Valve replacement]] prevents recurrence of [[mitral regurgitation]]. [[Mitral transcatheter edge to edge repair]] ([[TEER]]) with the [[MitraClip]] system is a minimal-invasive treatment option for secondary [[MR]]. Two [[RCTs]] ([[COAPT]] and [[MITRA-FR]]) demonstrated the safety and efficacy of [[procedure]] in [[patients]] with [[symptomatic]] [[heart failure]] and severe secondary [[MR]] despite [[medical therapy]], who are not eligible for [[surgery]].


==Overview==
==Surgical Therapy for Chronic Mitral Regurgitation==
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 <ref name="pmid18820172">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=Circulation | year= 2008 | volume= 118 | issue= 15 | pages= e523-661 | pmid=18820172 | doi=10.1161/CIRCULATIONAHA.108.190748 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18820172  }} </ref>. 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.
 
===Primary [[Mitral Regurgitation]]===
* Primary [[MR]] is a mechanical problem of the [[leaflet]] coaptation that needs [[ mitral valve]] mechanical intervention.
* Symptomatic [[patients]] with severe [[MR]] have worsened prognosis even with normal [[LV function]]. Therefore, the onset of [[symptoms ]]is an indication of [[mitral valve]] [[surgery]].<ref name="pmid20667334">{{cite journal |vauthors=Gillinov AM, Mihaljevic T, Blackstone EH, George K, Svensson LG, Nowicki ER, Sabik JF, Houghtaling PL, Griffin B |title=Should patients with severe degenerative mitral regurgitation delay surgery until symptoms develop? |journal=Ann Thorac Surg |volume=90 |issue=2 |pages=481–8 |date=August 2010 |pmid=20667334 |doi=10.1016/j.athoracsur.2010.03.101 |url=}}</ref>
*The goal of therapy in [[MR]] is to correct it before the onset of [[LV systolic dysfunction]].<ref name="pmid21821606">{{cite journal |vauthors=Tribouilloy C, Rusinaru D, Szymanski C, Mezghani S, Fournier A, Lévy F, Peltier M, Ben Ammar A, Carmi D, Remadi JP, Caus T, Touati G |title=Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction |journal=Eur J Echocardiogr |volume=12 |issue=9 |pages=702–10 |date=September 2011 |pmid=21821606 |doi=10.1093/ejechocard/jer128 |url=}}</ref>
* The ideal time for [[mitral valve]] surgery is when  there is not evidence of [[LV systolic dysfunction]] ([[LVEF]] ≤60% or [[LVESD]] ≥40 mm).<ref name="pmid16651470">{{cite journal |vauthors=Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, Schemper M, Maurer G, Baumgartner H |title=Outcome of watchful waiting in asymptomatic severe mitral regurgitation |journal=Circulation |volume=113 |issue=18 |pages=2238–44 |date=May 2006 |pmid=16651470 |doi=10.1161/CIRCULATIONAHA.105.599175 |url=}}</ref>
*Mitral valve repair is recommended in the expertise center. However, [[mitral valve replacement]] is preferable to a poor repair.
* [[ Annuloplasty]] and repair of the [[posterior leaflet]] have a lower [[mortality rate]] of <1%.<ref name="pmid16928491">{{cite journal |vauthors=Suri RM, Schaff HV, Dearani JA, Sundt TM, Daly RC, Mullany CJ, Enriquez-Sarano M, Orszulak TA |title=Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era |journal=Ann Thorac Surg |volume=82 |issue=3 |pages=819–26 |date=September 2006 |pmid=16928491 |doi=10.1016/j.athoracsur.2006.03.091 |url=}}</ref>
*The onset of [[symptoms]], [[LV dysfunction]], or [[pulmonary hypertension]] worsens the prognosis for [[MR]].
* [[MR]] may lead to progressively more severe [[MR]]  causing [[LV dilation]], stress on the [[mitral]] apparatus, further damage to the valve apparatus, more severe [[MR]], and further [[LV dilation]] and initiating a cycle of increasing [[LV]] volumes and [[MR]].<ref name="pmid19188506">{{cite journal |vauthors=Kang DH, Kim JH, Rim JH, Kim MJ, Yun SC, Song JM, Song H, Choi KJ, Song JK, Lee JW |title=Comparison of early surgery versus conventional treatment in asymptomatic severe mitral regurgitation |journal=Circulation |volume=119 |issue=6 |pages=797–804 |date=February 2009 |pmid=19188506 |doi=10.1161/CIRCULATIONAHA.108.802314 |url=}}</ref>
*Longstanding [[volume]] overload leads to irreversible [[LV dysfunction]] and a poorer prognosis.
*[[ Patients]] with severe [[MR]] who develop an [[LVEF]] <60% or LVESD ≥40 mm have already developed [[LV systolic dysfunction]].
*[[LV function]] and size returned to normal after [[mitral valve repair]] in a study.<ref name="pmid7641361">{{cite journal |vauthors=Starling MR |title=Effects of valve surgery on left ventricular contractile function in patients with long-term mitral regurgitation |journal=Circulation |volume=92 |issue=4 |pages=811–8 |date=August 1995 |pmid=7641361 |doi=10.1161/01.cir.92.4.811 |url=}}</ref>
*[[Mitral Transcatheter edge-to-edge repair]] (TEER) with the anterior and posterior leaflets clipped together at ≥1 location is safe and effective in treating severely symptomatic  [[primary MR]] who are at high risk for [[surgery]].
* Studies of TEER with a mitral valve clip showed improved [[symptoms]] and a reduction in [[MR]] by 2 to 3 grades, leading to reverse remodeling of the [[LV]].<ref name="pmid29096801">{{cite journal |vauthors=Sorajja P, Vemulapalli S, Feldman T, Mack M, Holmes DR, Stebbins A, Kar S, Thourani V, Ailawadi G |title=Outcomes With Transcatheter Mitral Valve Repair in the United States: An STS/ACC TVT Registry Report |journal=J Am Coll Cardiol |volume=70 |issue=19 |pages=2315–2327 |date=November 2017 |pmid=29096801 |doi=10.1016/j.jacc.2017.09.015 |url=}}</ref>
*[[Rheumatic mitral valve disease]] is less suitable for [[mitral repair]] compared with complex [[degenerative disease]].  
* In the presence of thickened or calcified leaflets, an extensive subvalvular disease with chordal fusion and shortening, and progression of [[rheumatic disease]] the durability of repair would be limited.
* Repair of [[rheumatic mitral valve disease]] should be limited to [[patients]] with less advanced [[disease ]] or in [[patients]] that [[mechanical prosthesis]] cannot be used because of [[anticoagulation]] contraindication.
*[[Mitral valve repair]] is recommended as follows:
:*Severe primary [[MR]] limited to less than one-half of the posterior leaflet
:* Inappropriate [[ Mitral valve replacement]]
*  [[Mortality rate]] of repair is <1%, long-term survival rate equivalent to that of age-matched general population, approximately 95% freedom from reoperation, and >80% freedom from recurrent moderate or severe (≥3) MR at 15 to 20 years after [[surgery]].<ref name="pmid27899396">{{cite journal |vauthors=Lazam S, Vanoverschelde JL, Tribouilloy C, Grigioni F, Suri RM, Avierinos JF, de Meester C, Barbieri A, Rusinaru D, Russo A, Pasquet A, Michelena HI, Huebner M, Maalouf J, Clavel MA, Szymanski C, Enriquez-Sarano M |title=Twenty-Year Outcome After Mitral Repair Versus Replacement for Severe Degenerative Mitral Regurgitation: Analysis of a Large, Prospective, Multicenter, International Registry |journal=Circulation |volume=135 |issue=5 |pages=410–422 |date=January 2017 |pmid=27899396 |doi=10.1161/CIRCULATIONAHA.116.023340 |url=}}</ref>
* [[Posterior leaflet repair]] is preferred to [[mitral valve replacement]] with a [[success rate]] ≥95%.


==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 inhibitor]]s and [[hydralazine]].  Studies have shown that the use of ACE inhibitors and hydralazine can delay surgical treatment of mitral regurgitation<ref name="pmid668075">{{cite journal |author=Greenberg BH, Massie BM, Brundage BH, Botvinick EH, Parmley WW, Chatterjee K |title=Beneficial effects of hydralazine in severe mitral regurgitation |journal=[[Circulation]] |volume=58 |issue=2 |pages=273–9 |year=1978 |month=August |pmid=668075 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=668075 |accessdate=2011-03-16}}</ref> <ref name="pmid10149580">{{cite journal |author=Hoit BD |title=Medical treatment of valvular heart disease |journal=[[Current Opinion in Cardiology]] |volume=6 |issue=2 |pages=207–11 |year=1991 |month=April |pmid=10149580 |doi= |url= |accessdate=2011-03-16}}</ref>.


==Surgical Therapy for Chronic Mitral Regurgitation==
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====
== 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid333321502">{{cite journal| author=Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F | display-authors=etal| title=2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 143 | issue= 5 | pages= e72-e227 | pmid=33332150 | doi=10.1161/CIR.0000000000000923 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=33332150 }}</ref> ==
*The ACC/AHA 2008 guidelines<ref name="pmid18848134">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| title=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. | journal=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 13 | pages= e1-142 | pmid=18848134 | doi=10.1016/j.jacc.2008.05.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848134 }} </ref> recommend [[mitral valve repair]] rather than [[mitral valve replacement]] if the anatomy is appropriate, including patients with [[rheumatic]] mitral valve disease<ref name="pmid10612761">{{cite journal| author=Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE| title=Mitral valve repair and replacement for rheumatic disease. | journal=J Thorac Cardiovasc Surg | year= 2000 | volume= 119 | issue= 1 | pages= 53-60 | pmid=10612761 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10612761  }} </ref> and mitral valve prolapse<ref name="pmid11568020">{{cite journal| author=Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M| title=Very long-term survival and durability of mitral valve repair for mitral valve prolapse. | journal=Circulation | year= 2001 | volume= 104 | issue= 12 Suppl 1 | pages= I1-I7 | pmid=11568020 | doi= | pmc= | url= }} </ref> (Grade 1C). The procedure should be performed at experienced surgical centers.
*Limited damage to certain areas of the mitral valve leaflets or [[chordae tendineae]]<ref name="pmid12830055">{{cite journal| author=Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R et al.| title=Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease. | journal=J Thorac Cardiovasc Surg | year= 2003 | volume= 125 | issue= 6 | pages= 1350-62 | pmid=12830055 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12830055  }} </ref>.
*Limited calcification of the leaflets or annulus
*[[Mitral valve prolapse|Prolapse]] of less than one-third of either leaflet
*Pure annular dilatation
*Valvular perforations
*Incomplete [[papillary muscle rupture]]


===Scenarios Favoring Mitral Valve Replacement===
=== Recommendations for Intervention for Chronic Primary MR Referenced studies that support the recommendations are summarized in the Online Data Supplement ===
*Extensive calcification or degeneration of a leaflet or annulus
{| class="wikitable"
*[[Mitral valve prolapse|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]]
==2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume=  | issue=  | pages=  | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref>==
===Recommendations for Mitral Valve Surgery===
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| colspan="1" style="text-align:center; background:LightGreen" | [[ESC guidelines classification scheme#Classification of Recommendations|Class I]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Mitral valve surgery]] is recommended for symptomatic patients with chronic severe primary [[mitral regurgitation]] (stage D) and [[LVEF]] greater than 30%. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
| bgcolor="LightGreen" |2.   In asymptomatic patients with severe primary MR and LV systolic dysfunction (LVEF ≤60%, LVESD ≥40 mm) (Stage C2), mitral valve surgery is recommended''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
3.   In patients with severe primary MR for whom surgery is indicated, mitral valve repair is recommended in preference to mitral valve replacement when the anatomic cause of MR is degenerative disease, if a successful and durable repair is possible.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Mitral valve surgery]] is recommended for asymptomatic patients with chronic severe primary [[mitral regurgitation]] and LV dysfunction (LVEF 30% to 60% and/or LVESD ≥40 mm, stage C2).  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Mitral valve repair]] is recommended in preference to [[mitral valve replacement]] (MVR) when surgical treatment is indicated for patients with chronic severe primary [[MR]] limited to the posterior leaflet. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |4.   In asymptomatic patients with severe primary MR and normal LV systolic function (LVEF ≥60% and LVESD ≤40 mm) (Stage C1), mitral valve repair is reasonable when the likelihood of a successful and durable repair without residual MR is >95% with an expected mortality rate of <1%, when it can be performed at a Primary or Comprehensive Valve Center.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
{| class="wikitable"
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Mitral valve repair]] is recommended in preference to [[MVR]] when surgical treatment is indicated for patients with chronic severe primary [[MR]] involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Concomitant [[mitral valve repair]] or [[MVR]] is indicated in patients with chronic severe primary [[MR]] undergoing cardiac surgery for other indications.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon" |5.   In asymptomatic patients with severe primary MR and normal LV systolic function (LVEF >60% and LVESD <40 mm) (Stage C1) but with a progressive increase in LV size or decrease in EF on ≥3 serial imaging studies, mitral valve surgery may be considered irrespective of the probability of a successful and durable repair''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C-LD]])''
|}
|}


{|class="wikitable"
=== Recommendations for Intervention for Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement ===
{| class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Mitral valve repair]] is reasonable in asymptomatic patients with chronic severe primary [[MR]] (stage C1) with preserved [[LV]] function ([[LVEF]] >60% and [[left ventricular]] end systolic dimension < 40 mm) in whom the likelihood of a successful and durable repair without residual [[MR]] is greater than 95% with an expected mortality rate of less than 1% when performed at a heart valve center of excellence.   ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
| bgcolor="LemonChiffon" |1.   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 ≤70  mm Hg. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R)]]''
2.   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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
|}
 
{| class="wikitable"
|-
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Mitral valve repair]] is reasonable for asymptomatic patients with chronic severe non-rheumatic primary [[MR]] (stage C1) and preserved [[LV]] function ([[LVEF]] >60% and [[left ventricular]] end systolic dimension <40 mm) in whom there is a high likelihood of a successful and durable repair with:
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ESC guidelines classification scheme#Classification of Recommendations|Class IIb]]
* New onset of [[atrial fibrillation]] or
* Resting [[pulmonary hypertension]] (pulmonary artery systolic arterial pressure >50 mm Hg).  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|-
| bgcolor="LemonChiffon" |3.   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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
4.   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 considered. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-NR]])''
5.   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 repair. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B-R]])''
|}
|}


==2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==


===Mitral Valve Surgery Indications (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===


{|class="wikitable"
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in primary mitral regurgitation'''
|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Mitral valve surgery]] is recommended for the symptomatic patient with acute severe [[MR]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
 
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Mitral valve surgery]] is beneficial for patients with chronic severe [[MR]] and [[NYHA]] functional class II, III, or IV symptoms in the absence of severe [[LV dysfunction]] (severe [[LV dysfunction]] is defined as [[ejection fraction]] less than 0.30) and/or end-systolic dimension greater than 55 mm. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Mitral valve surgery]] is beneficial for asymptomatic patients with chronic severe [[MR]] and mild to moderate [[LV dysfunction]], [[ejection fraction]] 0.30 to 0.60, and/or end-systolic dimension greater than or equal to 40 mm. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Mitral valve repair]] is considered  when the results of surgical technique  are expected to be durable<br>
❑ [[Surgery]] is recommended in  low risk symptomatic [[patients]] <br>
❑ [[Surgery]] is recommended in asymptomatic [[patients]] with [[LV dysfunction]] ([[LVESD]] ≥ 40 mm and/or [[LVEF]] ≤ 60%)
|-
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' [[Mitral valve repair]] is recommended over [[mitral valve replacement]] in the majority of patients with severe [[mitral Regurgitation Chronic|chronic mitral regurgiation]] who require surgery, and patients should be referred to surgical centers experienced in [[mitral valve repair]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|}
 
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|-
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[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]])<br>
❑[[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)<br>
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' [[Mitral valve surgery]] is not indicated for asymptomatic patients with [[MR]] and preserved [[LV function]] ([[ejection fraction]] greater than 0.60 and end-systolic dimension less than 40 mm) in whom significant doubt about the feasibility of repair exists. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence B]]) :'''
|-
|-
| bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Isolated [[mitral valve surgery]] is not indicated for patients with mild or moderate [[MR]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] may be considered in symptomatic [[patients]] who are inoperable due to high surgical risk, with [[echocardiographic]] criteria of eligibility<br>
|
|}
|}
<span style="font-size:85%">'''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]];
 
</span>
<br>


{|class="wikitable"
{|
|-
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=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 |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|-
|}
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Mitral valve repair]] is reasonable in experienced surgical centers for asymptomatic patients with chronic severe MR with preserved [[LV function]] ([[ejection fraction]] greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual MR is greater than 90%. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
 
|-
 
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Mitral valve surgery]] is reasonable for asymptomatic patients with chronic severe [[MR]], preserved [[LV function]], and new onset of [[atrial fibrillation]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
{{Family tree/start}}
|-
{{Family tree | | | | A01 | | | |A01= Management of patients with severe chronic primary [[mitral regurgitation]]}}
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Mitral valve surgery]] is reasonable for asymptomatic patients with chronic severe [[MR]], preserved [[LV function]], and [[pulmonary hypertension]] (pulmonary artery systolic pressure greater than 50 mm Hg at rest or greater than 60 mm Hg with exercise). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
{{Family tree | | | | |!| | | | | }}
|-
{{Family tree | | | | B01 | | | |B01= [[Symptoms]]}}
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' [[Mitral valve surgery]] is reasonable for patients with chronic severe [[MR]] due to a primary abnormality of the mitral apparatus and [[NYHA]] functional class III-IV symptoms and severe [[LV dysfunction]] ([[ejection fraction]] less than 0.30 and/or end-systolic dimension greater than 55 mm) in whom [[mitral valve repair]] is highly likely. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
{{Family tree | |,|-|-|^|-|-|-|-|-|-|-|-|-|.| | | | |}}
{{Family tree | C01 | | | | | | | | | |  C02| | | | |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | | | | | | | | |!| | | | |}}
{{Family tree | C03 | | | | | | | | | | |G2 | | | | | |C03=Determining the risk of [[surgery]]|G2=[[ LVEF]] ≤ 60% or
[[LVESD]] ≥ 40 mm}}
{{Family tree |,|^|-|-|-|.| | | | | | |,|^|-|-|-|.| |}}
{{Family tree | F1| | |F2 | | | | |R1 | | | R2  | | | | | |F1= High risk of [[futility]]
* [[Palliative]] therapy| F2= High risk for [[surgery]] or inoperable |R1=Yes|R2=NO  |}}
{{Family tree | | | |,|-|^|-|.| | | | |!| | | | | |!| }}
{{Family tree | | | F3| | |F4 | | |D1 | | | |D2 | | | | |F3=Yes|F4=NO|D1= [[Surgery]] |D2=New onset [[AF]] or [[SPAP]]>50 mmHg  }}
{{Family tree | | | |!| | | |!| | | | | | |,|-|-|-|^|.|}}
{{Family tree | | |F5 | | |F6 | | | | |H1 | |H2 | | | F5=[[TEER]] if anatomically suitable, optimal [[heart failure]] therapy|F6=[[Surgery]] ([[repair]] whenever possible)|H1=Yes, [[surgery]] |H2=NO }}
{{Family tree | | | | | | | | | | | | | | | | | | |!|}}
{{Family tree | | | | | | | | | | | | | | | | | | |H3 | |H3= High likelihood of durable [[repair]], low [[surgical]] risk, and [[LA]] dilatation}}
{{Family tree | | | | | | | | | | | | | | | | |,|-|^|.| | |}}
{{Family tree | | | | | | | | | | | | | | | | H4| |H5 | | | H5=Yes|H4=NO}}
{{Family tree | | | | | | | | | | | | | | | | |!| | |!| | | |}}
{{Family tree | | | | | | | | | | | | | | | |H6 | | H7| | |H7=[[Surgical]] [[mitral valve repair]]|H6=Follow-up |}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | |}}
{{Family tree/end}}
 
<span style="font-size:85%">'''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]];
 
</span>
<br>
 
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=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 |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}
|}


{|class="wikitable"
===Secondary [[Mitral Regurgitation]]===
|-
*The [[COAPT]] trial of transcatheter treatment of secondary [[MR]] showed improvement in [[survival]], [[hospitalization]], [[symptoms]], and [[quality of life]] in [[patients]] undergone [[TEER]] compared to only [[medical therapy]].<ref name="pmid31115470">{{cite journal |vauthors=Pibarot P, Delgado V, Bax JJ |title=MITRA-FR vs. COAPT: lessons from two trials with diametrically opposed results |journal=Eur Heart J Cardiovasc Imaging |volume=20 |issue=6 |pages=620–624 |date=June 2019 |pmid=31115470 |pmc=6529908 |doi=10.1093/ehjci/jez073 |url=}}</ref>
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
* A greater reduction in [[MR]] severity with [[TEER]] is associated with greater [[LV]] and [[LA]] [[reverse remodeling]].<ref name="pmid24014834">{{cite journal |vauthors=Grayburn PA, Foster E, Sangli C, Weissman NJ, Massaro J, Glower DG, Feldman T, Mauri L |title=Relationship between the magnitude of reduction in mitral regurgitation severity and left ventricular and left atrial reverse remodeling after MitraClip therapy |journal=Circulation |volume=128 |issue=15 |pages=1667–74 |date=October 2013 |pmid=24014834 |doi=10.1161/CIRCULATIONAHA.112.001039 |url=}}</ref><ref name="pmid30280640">{{cite journal |vauthors=Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim DS, Mishell JM, Whisenant B, Grayburn PA, Rinaldi M, Kapadia SR, Rajagopal V, Sarembock IJ, Brieke A, Marx SO, Cohen DJ, Weissman NJ, Mack MJ |title=Transcatheter Mitral-Valve Repair in Patients with Heart Failure |journal=N Engl J Med |volume=379 |issue=24 |pages=2307–2318 |date=December 2018 |pmid=30280640 |doi=10.1056/NEJMoa1806640 |url=}}</ref>
*MR may develop in [[patients]] with [[preserved LV systolic function]] who have progressive [[LA]] dilation, leading to enlargement of the [[mitral annulus]] and [[malcoaptation]] of the [[leafle]].
* This may arise in setting such as [[HF]] with preserved [[LVEF]], [[restrictive cardiomyopathy]], and [[nonobstructive hypertrophic cardiomyopathy]].
* Presence of [[AF]] in these [[patients]] contributes to the progression of [[LA]] and [[annular dilation]], thus increasing the severity of [[MR]].<ref name="pmid19552671">{{cite journal |vauthors=Kihara T, Gillinov AM, Takasaki K, Fukuda S, Song JM, Shiota M, Shiota T |title=Mitral regurgitation associated with mitral annular dilation in patients with lone atrial fibrillation: an echocardiographic study |journal=Echocardiography |volume=26 |issue=8 |pages=885–9 |date=September 2009 |pmid=19552671 |doi=10.1111/j.1540-8175.2009.00904.x |url=}}</ref>
* Successful ablation of [[AF]] may reduce or eliminate [[MR]].
* [[Mitral valve surgery]] was not associated with improved [[survival]] in [[symptomatic]] [[patients]] with secondary [[MR]].However, [[surgery]] may improve [[symptoms]] and [[quality of life]] in [[symptomatic]] [[patients]] despite [[medical therapy]].
* Small [[RCTs]] demonstrate that [[mitral valve]] [[surgery]] reduces [[chamber]] size and improves [[peak oxygen consumption]] in chronic severe secondary [[MR]].
* [[Ischemic]] or [[dilated cardiomyopathy]] are different challenges for [[mitral repair]].
*Regurgitation is caused by [[annular dilation]], as well as by apical and lateral displacement of the [[papillary muscles]].
*Progression of [[ventricular dilation]] has a negative effect on the long-term durability of the [[repair]].
*In an [[RCT]] of [[mitral valve repair]] versus [[mitral valve replacement]] in [[patients]] with severe [[ischemic]] [[MR]], there was no difference between repair and [[mitral valve replacement]] in [[survival rate]] or [[LV remodeling]] at 2 years. However, the rate of recurrence of moderate or severe [[MR]] over 2 years was higher in the repair group than in the replacement group, leading to a higher incidence of [[HF]] and repeat [[hospitalization]].<ref name="pmid19752354">{{cite journal |vauthors=Magne J, Girerd N, Sénéchal M, Mathieu P, Dagenais F, Dumesnil JG, Charbonneau E, Voisine P, Pibarot P |title=Mitral repair versus replacement for ischemic mitral regurgitation: comparison of short-term and long-term survival |journal=Circulation |volume=120 |issue=11 Suppl |pages=S104–11 |date=September 2009 |pmid=19752354 |doi=10.1161/CIRCULATIONAHA.108.843995 |url=}}</ref>
 
{{Family tree/start}}
{{Family tree | | | | A01 | | | |A01= Management of [[patients]] with chronic severe secondary [[mitral regurgitation]]}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= [[Symptomatic]] despite medical therapy}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | A01 | | | |A01=
*Optimazing [[medical therapy]]
* [[CRT]] implantation if indicated}}
{{Family tree | | | | |!| | | | | }}
{{Family tree | | | | B01 | | | |B01= Severe [[comorbidities]] or [[life expectancy]] < 1 year}}
{{Family tree | |,|-|-|^|-|-|.| | }}
{{Family tree | C01 | | | | C02 |C01= Yes| C02= NO}}
{{Family tree | |!| | | | | |!| | | | | | | | |}}
{{Family tree | F | | | | | E | | | | | | | | | F= [[Palliative]] care|E= Presence of [[CAD]] or other [[cardiac]] [[disease]] }}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | G | |  H| | | | | | | |H= NO| G=Yes |}}
{{Family tree | | | | | | |!| | |!| | | | | | | |}}
{{Family tree | | | | | | I | | J |-|P  | | | | |J= Persisting severe symptomatic secondary [[MR]]|P=[[Valve]] surgery if fulfilling criteria  |I=Appropriate for [[surgery]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | | K | | L | | | | | | | | | K=Yes|L=NO}}
{{Family tree | | | | | |!| | |!| | | | | | | | |}}
{{Family tree | | | | | N | |M  | | | | | | | | |N= [[CABG]], [[MV]] [[surgery]]|M= [[PCI]], [[TAVI]]}}
{{Family tree | | | | | | | | |!| | | | | |}}
{{Family tree | | | | | | | |T1 | | | | | | |T1=Persisting severe symptomatic secondary [[MR]]}}
{{Family tree | | | | | | |,|^|-|.| | | | | | | |}}
{{Family tree | | | | | | Q | | R | | | | | | | |Q=Yes
*Appropriate for [[valve]] [[surgery]] |R=NO
*Close [[follow-up]]}}
{{Family tree | | | | | |,|^|-|.| | | | | | | | |}}
{{Family tree | | | | |  S| | T | | | | | | | | |S= Yes
* [[MV]] [[surgery]] |T= NO
* End-stage [[LV]], [[RV failure]]}}
{{Family tree | | | | | | | |,|^|-|.| | | | | | |}}
{{Family tree | | | | | | | U | | V | | | | | | V=NO
*Fulfilling criteria suggesting an increased chance of responding to [[TEER]]|U= Yes
* [[Heart transplantation]], [[left ventricular assist devices]] palliative care| |}}
{{Family tree | | | | | | | | | |,|^|-|.| | | | |}}
{{Family tree | | | | | | | | | Y | |N  | | | | |Y=Yes
*[[TEER]] |N=NO
*[[Heart transplantation]], [[left ventricular assist devices]] palliative care, [[TEER ]] in selected cases or other [[transcatheter valve therapy]] if applicable for [[symptoms]] improvement}}


|-
{{Family tree/end}}
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Mitral valve repair]] may be considered for patients with chronic severe secondary MR due to severe [[LV dysfunction]] ([[ejection fraction]] less than 0.30) who have persistent [[NYHA]] functional class III-IV symptoms despite optimal therapy for [[heart failure]], including biventricular pacing. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=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 |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}
|}


===Mitral Valve Surgery in Adolescents (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===


{|class="wikitable"
<span style="font-size:85%">'''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]]
</span>
<br>
 
{| style="cellpadding=0; cellspacing= 0; width: 1000px;"
|-
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for intervention in chronic severe secondary mitral regurgitation'''
 
|-
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[MV surgery]] is indicated in the symptomatic adolescent or young adult with severe [[Mitral regurgitation|congenital MR]] with [[NYHA]] functional class III or IV symptoms. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[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>
|-
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[MV surgery]] is indicated in the asymptomatic adolescent or young adult with severe [[Mitral regurgitation|congenital MR]] and [[LV dysfunction|LV systolic dysfunction]] ([[ejection fraction]] less than or equal to 0.60). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | ''' ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|}
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[TEER]] should be considered in selected symptomatic [[patients]], not suitable for [[surgery]] and high likelihood of responding to [[TEER]]<br>


{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left | '''  ([[ ESC guidelines classification scheme|Class IIa, Level of Evidence C]]):'''
 
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[MV repair]] is reasonable in experienced surgical centers in the asymptomatic adolescent or young adult with severe [[Mitral regurgitation|congenital MR]] with preserved [[LV function|LV systolic function]] if the likelihood of successful repair without residual [[MR]] is greater than 90%.  ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|}
❑ In [[symptomatic]]  inoperable [[patients]], [[PCI]] (and/or[[ TAVI]]) possibly followed by [[TEER]] (in case of persisting severe secondary [[MR]]) should be considered<br>
 
{|class="wikitable"
|-
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''([[ESC guidelines classification scheme|Class IIb, Level of Evidence C]]) :'''
|-
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The effectiveness of [[MV surgery]] is not well established in asymptomatic adolescent or [[Mitral regurgitation|congenital MR]] young adult patients with severe and preserved [[LV function|LV systolic function]] in whom [[mitral valve replacement|valve replacement]] is highly likely. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])<nowiki>"</nowiki>
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ [[Valve]] [[surgery]] may be considered in [[symptomatic]] [[patients]] who are appropriate for [[surgery]]<br>
❑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<br>  
|
|}
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2021 ESC Guideline<ref name="pmid34453165">{{cite journal |vauthors=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 |title=2021 ESC/EACTS Guidelines for the management of valvular heart disease |journal=Eur Heart J |volume=43 |issue=7 |pages=561–632 |date=February 2022 |pmid=34453165 |doi=10.1093/eurheartj/ehab395 |url=}}</ref>
|-
|}
|}


==Sources==
 
*2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=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 |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>
<span style="font-size:85%">'''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]]
</span>
<br>


==References==
==References==

Latest revision as of 02:30, 8 December 2022
Intern
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Mitral regurgitation surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S. Synonyms and keywords: MR; Mitral regurgitation; LV; Left ventricle; LVESD; Left ventricular end systolic diameter; LVEF; Left ventricular ejection fraction; CABG; Coronary artery bypass grafting

Overview

Chronic secondary MR is associated with impaired prognosis and its management includes electrophysiological, transcatheter, and surgical interventions. Mitral valve surgery is recommended in patients with severe secondary MR undergoing CABG or other cardiac surgery. Decision of surgical approach should be individualized based on the patient characteristics. In selected patients without advanced LV remodelling, mitral valve repair resulted in improvement in symptoms, and reverse LV remodeling. Valve replacement prevents recurrence of mitral regurgitation. Mitral transcatheter edge to edge repair (TEER) with the MitraClip system is a minimal-invasive treatment option for secondary MR. Two RCTs (COAPT and MITRA-FR) demonstrated the safety and efficacy of procedure in patients with symptomatic heart failure and severe secondary MR despite medical therapy, who are not eligible for surgery.

Surgical Therapy for Chronic Mitral Regurgitation

Primary Mitral Regurgitation


2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[9]

Recommendations for Intervention for Chronic Primary MR Referenced studies that support the recommendations are summarized in the Online Data Supplement

Class I
2.   In asymptomatic patients with severe primary MR and LV systolic dysfunction (LVEF ≤60%, LVESD ≥40 mm) (Stage C2), mitral valve surgery is recommended(Level of Evidence: B-NR)

3.   In patients with severe primary MR for whom surgery is indicated, mitral valve repair is recommended in preference to mitral valve replacement when the anatomic cause of MR is degenerative disease, if a successful and durable repair is possible.(Level of Evidence: B-NR)

Class IIa
4.   In asymptomatic patients with severe primary MR and normal LV systolic function (LVEF ≥60% and LVESD ≤40 mm) (Stage C1), mitral valve repair is reasonable when the likelihood of a successful and durable repair without residual MR is >95% with an expected mortality rate of <1%, when it can be performed at a Primary or Comprehensive Valve Center.(Level of Evidence: B-NR)
Class IIb
5.   In asymptomatic patients with severe primary MR and normal LV systolic function (LVEF >60% and LVESD <40 mm) (Stage C1) but with a progressive increase in LV size or decrease in EF on ≥3 serial imaging studies, mitral valve surgery may be considered irrespective of the probability of a successful and durable repair(Level of Evidence: C-LD)

Recommendations for Intervention for Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement

Class IIa
1.   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 ≤70  mm Hg. (Level of Evidence: B-R)

2.   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. (Level of Evidence: B-NR)

Class IIb
3.   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. (Level of Evidence: B-NR)

4.   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 considered. (Level of Evidence: B-NR)

5.   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 repair. (Level of Evidence: B-R)


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[10]


 
 
 
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[10]

Secondary Mitral Regurgitation

 
 
 
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[10]


    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[10]


    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

    References

    1. ↑ Gillinov AM, Mihaljevic T, Blackstone EH, George K, Svensson LG, Nowicki ER, Sabik JF, Houghtaling PL, Griffin B (August 2010). "Should patients with severe degenerative mitral regurgitation delay surgery until symptoms develop?". Ann Thorac Surg. 90 (2): 481–8. doi:10.1016/j.athoracsur.2010.03.101. PMID 20667334.
    2. ↑ Tribouilloy C, Rusinaru D, Szymanski C, Mezghani S, Fournier A, Lévy F, Peltier M, Ben Ammar A, Carmi D, Remadi JP, Caus T, Touati G (September 2011). "Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction". Eur J Echocardiogr. 12 (9): 702–10. doi:10.1093/ejechocard/jer128. PMID 21821606.
    3. ↑ Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, Schemper M, Maurer G, Baumgartner H (May 2006). "Outcome of watchful waiting in asymptomatic severe mitral regurgitation". Circulation. 113 (18): 2238–44. doi:10.1161/CIRCULATIONAHA.105.599175. PMID 16651470.
    4. ↑ Suri RM, Schaff HV, Dearani JA, Sundt TM, Daly RC, Mullany CJ, Enriquez-Sarano M, Orszulak TA (September 2006). "Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era". Ann Thorac Surg. 82 (3): 819–26. doi:10.1016/j.athoracsur.2006.03.091. PMID 16928491.
    5. ↑ Kang DH, Kim JH, Rim JH, Kim MJ, Yun SC, Song JM, Song H, Choi KJ, Song JK, Lee JW (February 2009). "Comparison of early surgery versus conventional treatment in asymptomatic severe mitral regurgitation". Circulation. 119 (6): 797–804. doi:10.1161/CIRCULATIONAHA.108.802314. PMID 19188506.
    6. ↑ Starling MR (August 1995). "Effects of valve surgery on left ventricular contractile function in patients with long-term mitral regurgitation". Circulation. 92 (4): 811–8. doi:10.1161/01.cir.92.4.811. PMID 7641361.
    7. ↑ Sorajja P, Vemulapalli S, Feldman T, Mack M, Holmes DR, Stebbins A, Kar S, Thourani V, Ailawadi G (November 2017). "Outcomes With Transcatheter Mitral Valve Repair in the United States: An STS/ACC TVT Registry Report". J Am Coll Cardiol. 70 (19): 2315–2327. doi:10.1016/j.jacc.2017.09.015. PMID 29096801.
    8. ↑ Lazam S, Vanoverschelde JL, Tribouilloy C, Grigioni F, Suri RM, Avierinos JF, de Meester C, Barbieri A, Rusinaru D, Russo A, Pasquet A, Michelena HI, Huebner M, Maalouf J, Clavel MA, Szymanski C, Enriquez-Sarano M (January 2017). "Twenty-Year Outcome After Mitral Repair Versus Replacement for Severe Degenerative Mitral Regurgitation: Analysis of a Large, Prospective, Multicenter, International Registry". Circulation. 135 (5): 410–422. doi:10.1161/CIRCULATIONAHA.116.023340. PMID 27899396.
    9. ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check |pmid= value (help).
    10. ↑ 10.0 10.1 10.2 10.3 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).
    11. ↑ Pibarot P, Delgado V, Bax JJ (June 2019). "MITRA-FR vs. COAPT: lessons from two trials with diametrically opposed results". Eur Heart J Cardiovasc Imaging. 20 (6): 620–624. doi:10.1093/ehjci/jez073. PMC 6529908 Check |pmc= value (help). PMID 31115470.
    12. ↑ Grayburn PA, Foster E, Sangli C, Weissman NJ, Massaro J, Glower DG, Feldman T, Mauri L (October 2013). "Relationship between the magnitude of reduction in mitral regurgitation severity and left ventricular and left atrial reverse remodeling after MitraClip therapy". Circulation. 128 (15): 1667–74. doi:10.1161/CIRCULATIONAHA.112.001039. PMID 24014834.
    13. ↑ Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim DS, Mishell JM, Whisenant B, Grayburn PA, Rinaldi M, Kapadia SR, Rajagopal V, Sarembock IJ, Brieke A, Marx SO, Cohen DJ, Weissman NJ, Mack MJ (December 2018). "Transcatheter Mitral-Valve Repair in Patients with Heart Failure". N Engl J Med. 379 (24): 2307–2318. doi:10.1056/NEJMoa1806640. PMID 30280640.
    14. ↑ Kihara T, Gillinov AM, Takasaki K, Fukuda S, Song JM, Shiota M, Shiota T (September 2009). "Mitral regurgitation associated with mitral annular dilation in patients with lone atrial fibrillation: an echocardiographic study". Echocardiography. 26 (8): 885–9. doi:10.1111/j.1540-8175.2009.00904.x. PMID 19552671.
    15. ↑ Magne J, Girerd N, Sénéchal M, Mathieu P, Dagenais F, Dumesnil JG, Charbonneau E, Voisine P, Pibarot P (September 2009). "Mitral repair versus replacement for ischemic mitral regurgitation: comparison of short-term and long-term survival". Circulation. 120 (11 Suppl): S104–11. doi:10.1161/CIRCULATIONAHA.108.843995. PMID 19752354.

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