Mitral regurgitation surgery indications: Difference between revisions
| Line 19: | Line 19: | ||
* Primary [[MR]] is a mechanical problem of the [[leaflet]] coaptation that needs [[ mitral valve]] mechanical intervention. | * 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> | * 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]]. | *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> | * 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. | *Mitral valve repair is recommended in the expertise center. However, [[mitral valve replacement]] is preferable to a poor repair. | ||
Revision as of 15:32, 10 June 2022
 |
Intern Survival Guide |
|
Mitral regurgitation surgery | |
|
Treatment | |
|---|---|
|
Mitral regurgitation surgery indications On the Web | |
|
American Roentgen Ray Society Images of Mitral regurgitation surgery indications | |
|
Directions to Hospitals Performing Mitral regurgitation surgery | |
|
Risk calculators and risk factors for Mitral regurgitation surgery indications | |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Vasodilator therapy with ACE inhibitors and hydralazine is the mainstay of therapy in patient with chronic compensated mitral regurgitation. Acute mitral regurgitation requires urgent mitral valve repair or mitral valve replacement. MV surgery is indicated in patients with chronic aortic regurgitation who develop symptomatic mitral valve regurgitation. It is also indicated in patients with abnormalities in LV size or function (These include a left ventricular ejection fraction (LVEF) of less than 60% and a left ventricular end systolic dimension (LVESD) of greater than 45 mm), pulmonary hypertension, or new onset atrial fibrillation even without symptoms [1]. The patient with severe LV dysfunction (an LVEF < 30% and/or a left ventricular end-systolic dimension greater than 55 mm) poses a higher risk but may undergo surgery if chordal preservation is likely. MV repair is recommended over MV replacement in the majority of patients with severe chronic MR who require surgery, and patients should be referred to surgical centers experienced in MV repair.
Medical Therapy of Chronic Mitral Regurgitation
Vasodilator therapy is a mainstay of medical therapy in the management of chronic mitral regurgitation. In the chronic state, the most commonly used agents are ACE inhibitors and hydralazine. Studies have shown that the use of ACE inhibitors and hydralazine can delay surgical treatment of mitral regurgitation[2] [3].
Surgical Therapy for Chronic Mitral Regurgitation
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.[4]
- The goal of therapy in MR is to correct it before the onset of LV systolic dysfunction.[5]
- The ideal time for mitral valve surgery is when there is not evidence of LV systolic dysfunction (LVEF ≤60% or LVESD ≥40 mm).[6]
- 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%.
| 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 | |
| (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) | |
| (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[7] |
|---|
| 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[7] |
|---|
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.[8]
- A greater reduction in MR severity with TEER is associated with greater LV and LA reverse remodeling.[9][10]
- 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.[11]
- 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.[12]
| Management of patients with chronic severe secondary mitral regurgitation | |||||||||||||||||||||||||||||||||||||||
| Symptomatic despite medical therapy | |||||||||||||||||||||||||||||||||||||||
*Optimazing medical therapy
| |||||||||||||||||||||||||||||||||||||||
| 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
| ||||||||||||||||||||||||||||||||||||||
| Yes | NO
| ||||||||||||||||||||||||||||||||||||||
Yes
| NO
| ||||||||||||||||||||||||||||||||||||||
| Yes | NO
| ||||||||||||||||||||||||||||||||||||||
| The above algorithm adopted from 2021 ESC Guideline[7] |
|---|
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 | |
| (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 |
| The above table adopted from 2021 ESC Guideline[7] |
|---|
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
- ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
- ↑ Greenberg BH, Massie BM, Brundage BH, Botvinick EH, Parmley WW, Chatterjee K (1978). "Beneficial effects of hydralazine in severe mitral regurgitation". Circulation. 58 (2): 273–9. PMID 668075. Retrieved 2011-03-16. Unknown parameter
|month=ignored (help) - ↑ Hoit BD (1991). "Medical treatment of valvular heart disease". Current Opinion in Cardiology. 6 (2): 207–11. PMID 10149580. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ 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.
- ↑ 7.0 7.1 7.2 7.3 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.