Chronic mitral regurgitation treatment: Difference between revisions
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==Medical Therapy of Chronic Mitral Regurgitation== | ==Medical Therapy of Chronic Mitral Regurgitation== | ||
In MR, [[left ventricular systolic dysfunction]] | In MR, [[left ventricular systolic dysfunction]] and subsequent [[heart failure]] might occur. [[Mitral regurgitation surgery|Surgery]] is generally the treatment of choice among MR patients with [[left ventricular systolic dysfunction]]; nevertheless, medical therapy is warranted when surgery is delayed or not planned. | ||
Although the body of literature for medical therapy in MR is not robust, the existing sparse data suggests that patients with MR who experience | Although the body of literature for medical therapy in MR is not robust, the existing sparse data suggests that patients with MR who experience [[left ventricular systolic dysfunction]] are candidate for the standard therapy of [[heart failure]], which includes [[beta blocker]]s, [[angiotensin converting enzyme inhibitor]]s, [[angiotensin receptor blocker]]s, or [[aldosterone antagonist]]. [[Beta blocker]] use is associated with improved left ventricular function.<ref name="pmid7911128">{{cite journal| author=Tsutsui H, Spinale FG, Nagatsu M, Schmid PG, Ishihara K, DeFreyte G et al.| title=Effects of chronic beta-adrenergic blockade on the left ventricular and cardiocyte abnormalities of chronic canine mitral regurgitation. | journal=J Clin Invest | year= 1994 | volume= 93 | issue= 6 | pages= 2639-48 | pmid=7911128 | doi=10.1172/JCI117277 | pmc=PMC294505 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7911128 }} </ref><ref name="pmid22818065">{{cite journal| author=Ahmed MI, Aban I, Lloyd SG, Gupta H, Howard G, Inusah S et al.| title=A randomized controlled phase IIb trial of beta(1)-receptor blockade for chronic degenerative mitral regurgitation. | journal=J Am Coll Cardiol | year= 2012 | volume= 60 | issue= 9 | pages= 833-8 | pmid=22818065 | doi=10.1016/j.jacc.2012.04.029 | pmc=PMC3914413 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22818065 }} </ref> | ||
he administration of [[vasodilator]] is useful among patients with acute severe MR and those who have [[hypertension]]. The benefits of [[vasodilator]] use in asymptomatic patients with normal blood pressure is not established, and might even be associated with worsening of the severity of MR. The administration of [[vasodilator]]s in this category of MR patients is therefore not recommended. | |||
==Surgical Therapy for Chronic Mitral Regurgitation== | ==Surgical Therapy for Chronic Mitral Regurgitation== | ||
Revision as of 14:11, 3 September 2014
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-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
In MR, left ventricular systolic dysfunction and subsequent heart failure might occur. Surgery is generally the treatment of choice among MR patients with left ventricular systolic dysfunction; nevertheless, medical therapy is warranted when surgery is delayed or not planned.
Although the body of literature for medical therapy in MR is not robust, the existing sparse data suggests that patients with MR who experience left ventricular systolic dysfunction are candidate for the standard therapy of heart failure, which includes beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonist. Beta blocker use is associated with improved left ventricular function.[2][3]
he administration of vasodilator is useful among patients with acute severe MR and those who have hypertension. The benefits of vasodilator use in asymptomatic patients with normal blood pressure is not established, and might even be associated with worsening of the severity of MR. The administration of vasodilators in this category of MR patients is therefore not recommended.
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.
Indications for Surgery in Chronic Mitral Regurgitation
The indications for surgery in chronic mitral regurgitation are:
- Severe organic MR.
- Left ventricular dysfunction - ejection fraction <60% and end systolic diameter >40 mm2.
- Surgery can be considered in asymptomatic patients in the following cases:
- Truly severe MR
- Low operative mortality
- High chance of successful repair (e.g: posterior leaflet - MVP)
- Pre-operative ejection fraction has a prognostic impact in patients who undergo mitral valve repair or replacement. The lower the ejection fraction is, the higher the mortality is.
Why the Mitral Valve is Replaced Before Symptoms in Patients with Chronic Mitral Regurgitation
- Mitral regurgitation is a syndrome of pure volume overload whereas aortic regurgitation is a combination of both volume and pressure overload.
- Both syndromes are associated with an increase in preload.
- In mitral regurgitation, the afterload is reduced whereas in aortic regurgitation the afterload is increased. This is very important because when the mitral valve is repaired, there is no longer a reduction afterload and the left ventricle may fail due to an abrupt rise in the afterload. In aortic regurgitation, because the afterload is already increased chronically, replacement of the valve is not as likely to precipitate acute left ventricular failure due to an abrupt rise in afterload.
- By the time symptoms develop, there is already left ventricular dysfunction.
- Because of the low pressure system into which the blood is ejected into through the mitral valve, the ejection fraction is always high in mitral regurgitation. If the ejection fraction appears to be "normal", there is already decline in left ventricular function.
- There is no indication for vasodilator therapy in the absence of systemic hypertension in asymptomatic patients with preserved 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
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary[8]
Recommendations for Chronic Primary Mitral Regurgitation
| Class IIa |
| "1. Medical therapy for systolic dysfunction is reasonable in symptomatic patients with chronic primary mitral regurgitation (stage D) and LVEF less than 60% in whom surgery is not contemplated. (Level of Evidence: B)" |
| Class III |
| "1.Vasodilator therapy is not indicated for normotensive asymptomatic patients with chronic primary MR (stages B and C1) and normal systolic LV function.(Level of Evidence: B) " |
Recommendations for Chronic Secondary Mitral Regurgitation
| Class I |
| "1.Patients with chronic secondary MR (stages B to D) and heart failure with reduced LVEF should receive standard GDMT (guideline directed medical therapy) therapy for heart failure, including ACE inhibitors, ARBs, beta blockers, and/or aldosterone antagonists as indicated. (Level of Evidence: A) " |
| "2.Cardiac resynchronization therapy with biventricular pacing is recommended for symptomatic patients with chronic severe secondary MR (stages B to D) who meet the indications for device therapy. (Level of Evidence: A) " |
ACC/AHA Guidelines- Indications for Surgery for Mitral Regurgitation (DO NOT EDIT) [4]
| Class I |
| "1.MV surgery is recommended for the symptomatic patient with acute severe MR.(Level of Evidence: B) " |
| "2.MV 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.MV 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.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.(Level of Evidence: C) " |
| Class IIa |
| "1.MV 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.MV surgery is reasonable for asymptomatic patients with chronic severe MR, preserved LV function, and new onset of atrial fibrillation.(Level of Evidence: C) " |
| "3.MV 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.MV 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 MV repair is highly likely.(Level of Evidence: C) " |
| Class IIb |
| "1.MV 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) " |
| Class III |
| "1.MV 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 MV surgery is not indicated for patients with mild or moderate MR.(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.
- ↑ Tsutsui H, Spinale FG, Nagatsu M, Schmid PG, Ishihara K, DeFreyte G; et al. (1994). "Effects of chronic beta-adrenergic blockade on the left ventricular and cardiocyte abnormalities of chronic canine mitral regurgitation". J Clin Invest. 93 (6): 2639–48. doi:10.1172/JCI117277. PMC 294505. PMID 7911128.
- ↑ Ahmed MI, Aban I, Lloyd SG, Gupta H, Howard G, Inusah S; et al. (2012). "A randomized controlled phase IIb trial of beta(1)-receptor blockade for chronic degenerative mitral regurgitation". J Am Coll Cardiol. 60 (9): 833–8. doi:10.1016/j.jacc.2012.04.029. PMC 3914413. PMID 22818065.
- ↑ 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.
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "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". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.