Mitral regurgitation surgery indications: Difference between revisions
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*Extensive damage of mitral valve secondary to [[endocarditis]] | *Extensive damage of mitral valve secondary to [[endocarditis]] | ||
==ACC/AHA Guidelines- Indications for Surgery | ==2008 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease - Indications for Mitral Valve Surgery in Mitral Regurgitation (DO NOT EDIT) <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>== | ||
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]=== | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| 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> | |||
|- | |||
| 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> | |||
|- | |||
| 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> | |||
|- | |||
| 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> | |||
|} | |||
'''1.''' | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] | |||
|- | |||
| 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> | |||
|- | |||
| 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> | |||
|} | |||
'''2.''' | {|class="wikitable" | ||
|- | |||
| 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> | |||
|- | |||
| 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> | |||
|- | |||
| 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> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | |||
|- | |||
| 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> | |||
|} | |||
==Sources== | ==Sources== | ||
*2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <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>. | *2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <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>. | ||
Revision as of 18:10, 29 October 2012
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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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Directions to Hospitals Performing Mitral regurgitation surgery | |
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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 theray 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
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
- The ACC/AHA 2008 guidelines[4] recommend mitral valve repair rather than mitral valve replacement if the anatomy is appropriate, including patients with rheumatic mitral valve disease[5] and mitral valve prolapse[6] (Grade 1C). The procedure should be performed at experienced surgical centers.
- Limited damage to certain areas of the mitral valve leaflets or chordae tendineae[7].
- Limited calcification of the leaflets or annulus
- Prolapse of less than one-third of either leaflet
- Pure annular dilatation
- Valvular perforations
- Incomplete papillary muscle rupture
Scenarios Favoring Mitral Valve Replacement
- Extensive calcification or degeneration of a leaflet or annulus
- Prolapse of more than one-third of the leaflet tissue
- Extensive chordal fusion, calcification, or papillary muscle rupture
- Extensive damage of mitral valve secondary to endocarditis
2008 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease - Indications for Mitral Valve Surgery in Mitral Regurgitation (DO NOT EDIT) [4]
| Class I |
| "1. Mitral valve surgery is recommended for the symptomatic patient with acute severe MR. (Level of Evidence: B)" |
| "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. (Level of Evidence: B)" |
| "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. (Level of Evidence: B)" |
| "4. Mitral valve repair is recommended over mitral valve replacement in the majority of patients with severe chronic mitral regurgiation who require surgery, and patients should be referred to surgical centers experienced in mitral valve repair. (Level of Evidence: C)" |
| Class III |
| "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. (Level of Evidence: C)" |
| "2. Isolated mitral valve surgery is not indicated for patients with mild or moderate MR. (Level of Evidence: C)" |
| Class IIa |
| "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%. (Level of Evidence: B)" |
| "2. Mitral valve surgery is reasonable for asymptomatic patients with chronic severe MR, preserved LV function, and new onset of atrial fibrillation. (Level of Evidence: C)" |
| "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). (Level of Evidence: C)" |
| "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. (Level of Evidence: C)" |
| Class IIb |
| "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. (Level of Evidence: C)" |
Sources
- 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [4].
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) - ↑ 4.0 4.1 4.2 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD; et al. (2008). "2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (13): e1–142. doi:10.1016/j.jacc.2008.05.007. PMID 18848134.
- ↑ Yau TM, El-Ghoneimi YA, Armstrong S, Ivanov J, David TE (2000). "Mitral valve repair and replacement for rheumatic disease". J Thorac Cardiovasc Surg. 119 (1): 53–60. PMID 10612761.
- ↑ Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M (2001). "Very long-term survival and durability of mitral valve repair for mitral valve prolapse". Circulation. 104 (12 Suppl 1): I1–I7. PMID 11568020.
- ↑ Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R; et al. (2003). "Repair versus replacement for degenerative mitral valve disease with coexisting ischemic heart disease". J Thorac Cardiovasc Surg. 125 (6): 1350–62. PMID 12830055.