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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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 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
| 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[4] |
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| 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[4] |
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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[4] |
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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
| 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[4] |
|---|
Primary MR is a mechanical problem of the leaflet coaptation that has only a mechanical solution—that of mitral valve mechanical intervention. The onset of symptoms that results from severe MR worsens prognosis even when LV function appears to be normal,1,2 and the negative prognosis extends even to mild symptoms.2 Thus, the onset of symptoms is an indication for prompt mitral valve surgery.
2.
The goal of therapy in MR is to correct it before the onset of LV systolic dysfunction and its subsequent adverse effect on patient outcomes. The ideal time for mitral valve surgery is when the patient’s LV approaches but has not yet reached the parameters that indicate systolic dysfunction (LVEF ≤60% or LVESD ≥40 mm).3–7,16 Because symptoms do not always coincide with LV dysfunction, imaging surveillance is used to plan surgery before severe dysfunction has occurred. If moderate LV dysfunction is already present, prognosis is worse after mitral valve operation.5–7,9,10,16 Thus, further delay (although symptoms are absent) will lead to greater LV dysfunction and a still worse prognosis. Because the loading conditions in MR allow continued late ejection into a lower-impedance LA, a higher cutoff for “normal” LVEF is used in MR than in other types of heart disease. Although it is clearly inadvisable to allow patients’ LV function to deteriorate beyond the benchmarks of an LVEF ≤60% or LVESD ≥40 mm, some recovery of LV function can still occur even if these thresholds have been crossed.5,32
3.
Repair success increases with surgical volume and expertise, which is a principle guiding surgical referral.21,27 However, mitral valve replacement is preferable to a poor repair. The results of a minimally invasive approach may be similar to those of a full median sternotomy if the minimally invasive operation is performed by highly experienced surgeons.33–38 When leaflet dysfunction is limited so that only annuloplasty and repair of the posterior leaflet are necessary, an operative mortality rate of <1%, long-term survival rate equivalent to that of the age-matched general population, approximately 95% freedom from reoperation, and >80% freedom from recurrent moderate or severe MR at 15 to 20 years after operation are expected.23,24,39,40
4.
The onset of symptoms, LV dysfunction, or pulmonary hypertension worsens the prognosis for MR. Careful surveillance may result in timing of valve surgery before these negative sequelae occur. However, an attractive alternative strategy for treating severe chronic primary MR is to perform early mitral repair before these triggers are reached. Early mitral repair avoids the need for intensive surveillance and also obviates the possibility that patients might become lost to follow-up or delay seeing their clinician until advanced LV dysfunction has already ensued.4,13,16,22 For the early mitral repair strategy to be effective, a durable repair must be provided. An unwanted valve replacement and its attendant risks, or a failed repair necessitating reoperation, could be a complication of this approach. Thus, there must be a high degree of certainty that a durable repair can be performed. This certainty comes from the track record of the surgical team in operating on the specific type of lesion under consideration. Thus, asymptomatic patients should be treated in a Comprehensive Valve Center.21,24,27–29 In excellent hands, patients with severe MR from flail leaflets who undergo early operation as opposed to watchful waiting have a lower risk of developing HF and lower mortality rates.4,13,15
5.
MR may lead to progressively more severe MR as the initial level of MR causes LV dilation, which increases stress on the mitral apparatus, causing further damage to the valve apparatus, more severe MR, and further LV dilation—thus initiating a perpetual cycle of ever-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.5,6 One study has suggested that for LV function and size to return to normal after mitral valve repair, the LVEF should be >64% and LVESD <37 mm.16 Thus, when longitudinal follow-up demonstrates a progressive decrease of LVEF toward 60% or a progressive increase in LVESD approaching 40 mm, it is reasonable to consider intervention.41 In severe MR, TTE is recommended at 3- to 6-month intervals or more frequently as the ventricle enlarges.
6.
Mitral transcatheter edge-to-edge repair (TEER) with the anterior and posterior leaflets clipped together at ≥1 locations is safe and effective in treating severely symptomatic patients with primary MR who are at high or prohibitive surgical risk.17,18,42 Studies of TEER with a mitral valve clip have demonstrated improved symptoms and a reduction in MR by 2 to 3 grades, leading to reverse remodeling of the LV. Superior outcomes were shown with surgery versus TEER, and thus it is only the patients who are at high or prohibitive risk for surgery for whom TEER is performed.
7.
Rheumatic mitral valve disease is less suitable for mitral repair compared with complex degenerative disease. Durability of the repair is limited by thickened or calcified leaflets, extensive subvalvular disease with chordal fusion and shortening, and progression of rheumatic disease. Freedom from reoperation at 20 years, even in experienced hands, is in the 50% to 60% range. In a large series from Korea, repair was accomplished in 22% of patients operated on for rheumatic disease.19 One-third of these patients who underwent repair had significant stenosis or regurgitation at 10 years. Repair of rheumatic mitral valve disease should be limited to patients with less advanced disease in whom a durable repair can be accomplished or to patients in whom a mechanical prosthesis cannot be used because of anticoagulation management concerns.43
8.
Mitral valve repair is the procedure of choice for isolated severe primary MR limited to less than one-half of the posterior leaflet, and mitral valve replacement is inappropriate unless mitral valve repair has been attempted and was unsuccessful.11–14,21,22 Surgical repair of primary MR has been remarkably successful. Repair of isolated degenerative mitral disease, when leaflet dysfunction is sufficiently limited that only annuloplasty and repair of the posterior leaflet are necessary, has led to outcomes distinctly superior to those with biological or mechanical mitral valve replacement.11–14 Repair is associated with an operative mortality rate of <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.15,39 As much as one-half of the posterior leaflet may be excised, plicated, or resuspended. Posterior leaflet repair has become sufficiently standardized in this situation so that repair, rather than mitral valve replacement, is the standard of care. Execution of this procedure with a success rate ≥95% should be the expectation of every cardiac surgeon who performs mitral valve procedures.
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[5] recommend mitral valve repair rather than mitral valve replacement if the anatomy is appropriate, including patients with rheumatic mitral valve disease[6] and mitral valve prolapse[7] (Grade 1C). The procedure should be performed at experienced surgical centers.
- Limited damage to certain areas of the mitral valve leaflets or chordae tendineae[8].
- 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
Sources
- 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease [1]
References
- ↑ 1.0 1.1 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 4.3 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). - ↑ 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.