Mitral regurgitation surgery indications
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Intern Survival Guide |
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Mitral regurgitation surgery | |
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Treatment | |
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Mitral regurgitation surgery indications On the Web | |
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American Roentgen Ray Society Images of Mitral regurgitation surgery indications | |
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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
- 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.[1]
- The goal of therapy in MR is to correct it before the onset of LV systolic dysfunction.[2]
- The ideal time for mitral valve surgery is when there is not evidence of LV systolic dysfunction (LVEF ≤60% or LVESD ≥40 mm).[3]
- 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%.[4]
- 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.[5]
- 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.[6]
- 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.[7]
- 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.[8]
- Posterior leaflet repair is preferred to mitral valve replacement with a success rate ≥95%.
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): | |
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❑ Mitral valve repair is considered when the results of surgical technique are expected to be durable | |
| (Class IIa, Level of Evidence B): | |
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❑ 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) | |
| (Class IIb, Level of Evidence B) : | |
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❑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] |
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| 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] |
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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.[11]
- A greater reduction in MR severity with TEER is associated with greater LV and LA reverse remodeling.[12][13]
- 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.[14]
- 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.[15]
| Management of patients with chronic severe secondary mitral regurgitation | |||||||||||||||||||||||||||||||||||||||
| Symptomatic despite medical therapy | |||||||||||||||||||||||||||||||||||||||
*Optimazing medical therapy
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| 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
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| Yes | NO
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Yes
| NO
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| Yes | NO
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| The above algorithm adopted from 2021 ESC Guideline[10] |
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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): | |
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❑ Valve surgery/intervention is recommended in symptomatic severe secondary MR despite medical therapy or CRT | |
| (Class IIa, Level of Evidence B): | |
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❑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): | |
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❑ 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) : | |
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❑ Valve surgery may be considered in symptomatic patients who are appropriate for surgery |
| The above table adopted from 2021 ESC Guideline[10] |
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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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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). - ↑ 10.0 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). - ↑ 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. - ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.