Mitral regurgitation surgery indications

Intern Survival Guide

Mitral regurgitation surgery
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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 . 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 .

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

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 Appropriate for valve surgery

NO Close follow-up

Yes MV surgery

NO End-stage LV, RV failure

Yes Heart transplantation, left ventricular assist devices palliative care

NO Fulfilling criteria suggesting an increased chance of responding to TEER

Yes TEER

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

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

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 Palliative therapy

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

Primary MR

• 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.
• The goal of therapy in MR is to correct it before the onset of LV systolic dysfunction.
• The ideal time for mitral valve surgery is when there is not evidence of LV systolic dysfunction (LVEF ≤60% or LVESD ≥40 mm).
• 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%.
• 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.
• 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.
• 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.
• 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.
• Posterior leaflet repair is preferred to mitral valve replacement with a success rate ≥95%.

Secondary MR]]

The COAPT trial of transcatheter treatment of secondary MR demonstrated improvement in survival, hospitalization, symptoms, and quality of life in patients with persistent symptoms despite optimization of GDMT who were randomized to TEER, as compared with those randomized to continued GDMT. In contrast, MITRA-FR (Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation) enrolled patients with greater degrees of LV enlargement and less severe MR (mean ERO area 0.31 cm2 versus 0.41 cm2) and reported no benefit of TEER in reducing the composite endpoint of death or hospitalization as compared with medical therapy. In addition, the inclusion criterion in MITRA-FR of an LVESD up to 70 mm represents extreme dilation; in contrast, in the COAPT trial, the mean LVESD was smaller (52±9 mm), and even the LVEDD rarely exceeded 70 mm (mean 62±7 mm). Thus, the enrollment criteria in COAPT trial (LVEF between 20% and 50%, LVESD ≤70 mm, pulmonary artery systolic pressure ≤70 mm Hg, and persistent symptoms [NYHA class II, III, or IV] while on optimal GDMT) are the current standard selection criteria for TEER for secondary MR. Observational studies have suggested that a greater reduction in MR severity with TEER is associated with greater LV and LA reverse remodeling.1–8,48,49 The exact anatomy and mechanism of MR also needs to be taken into consideration when determining candidacy for transcatheter repair. 2. There is no proof that surgical correction of chronic secondary MR is effective in prolonging life, but observational studies and a substudy of the randomized STICH trial suggest that it is wise to address the mitral valve during CABG for severe CAD when secondary MR is severe. Although it may be hoped that the revascularization will recruit hibernating myocardium and reduce chronic secondary MR, this has not been demonstrated, and failing to correct chronic severe secondary MR may leave the patient with severe residual MR. The risks and benefits of additional surgical interventions should be weighed in patients with LV systolic dysfunction.9–13 For patients with secondary MR undergoing operation for other valve disease, see Section 10.2 (Timing of Intervention for Mixed Valve Disease). 3. 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 leaflets.51,52 This may arise in conditions such as HF with preserved LVEF, restrictive cardiomyopathy, and nonobstructive hypertrophic cardiomyopathy. These patients often have associated AF, which may contribute to the progression of LA and annular dilation, thus increasing the severity of MR,18,53 and successful ablation of AF may reduce or eliminate MR.53 Isolated annular dilation accounts for <20% of patients referred for surgery of severe MR in the STS database, but it is also the etiology with the highest mitral valve repair rates (85%).16,17 The limited data addressing mitral valve repair in patients with annular dilation related to AF indicate low operative risk.18–20 4. There is limited evidence that mitral valve surgery improves survival in symptomatic patients with secondary MR. In addition, surgery may improve symptoms and quality of life in these patients whose symptoms persist despite GDMT. Small RCTs demonstrate that mitral valve surgery reduces chamber size and improves peak oxygen consumption in chronic severe secondary MR. Ischemic or dilated cardiomyopathy presents different challenges for mitral repair. Regurgitation is caused by annular dilation, as well as by apical and lateral displacement of the papillary muscles. New techniques have facilitated mitral repair in this situation, but durability of the repair is dependent primarily on regression or progression of ventricular dilation. If the heart continues to dilate, long-term durability of the repair is moot; the survival of the patient is limited.9,12,21–43 5. 5. 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. The lack of apparent benefit of valve repair over valve replacement in secondary MR versus primary MR, with less durable repairs in secondary MR, highlights that primary and secondary MR are 2 different diseases.