Mitral regurgitation surgery indications
|
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: Mohammed A. Sbeih, M.D. [2]
Indications
Surgery is indicated in patients with symptomatic mitral valve regurgitation, also it is 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.
ACC/AHA guidelines recommend that patients with chronic MR who become symptomatic are candidates for corrective mitral surgery [1], even if the symptoms improve with medical therapy or the left ventricle appears to be compensated [1].
Surgery may be recommended in asymptomatic patients with preserved left ventricular function if the surgery performed in a center in which the likelihood of successful surgery is greater than 90 percent, otherwise; the patient can be safely treated with watchful waiting as long as the patient is carefully monitored [2]. The pstient should be seen every 6 to 12 months. Echocardiography should be obtained at these visits. The early surgery exposes the patient to perioperative morbidity and mortality as well as the long-term complications of a prosthetic valve. But it is important to have an objective measure of LV function in patients with asymptomatic MR, because there may be benefit from surgery prior to the onset of symptoms of the depression of the ventricular function in some cases. In patients with borderline values of ventricular size or function in whom access to such monitoring is limited; Surgery may be done earlier.
| Symptoms | LV EF | LVESD |
|---|---|---|
| NYHA II - IV | > 60 percent | < 45 mm |
| Asymptomatic or symptomatic | 50 - 60 percent | ≥ 45 mm |
| Asymptomatic or symptomatic | < 50 percent or ≥ 45 mm | |
| Pulmonary artery systolic pressure ≥ 50 mmHg | ||
The patient may also need valve surgery in the following conditions:
- The changes in the mitral valve are causing major heart symptoms, such as angina (chest pain), shortness of breath, fainting spells (syncope), or heart failure.
- Tests show that the changes in your mitral valve are beginning to seriously affect your heart function.
- The heart valve has been damaged by endocarditis (infection of the heart valve).
- The patient has received a new heart valve in the past, and it is not working well, or you have other problems such as blood clots, infection, or bleeding.
Mitral valve repair is recommended in following:
- Limited damage to certain areas of the mitral valve leaflets or chordae tendineae[4].
- 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.
Mitral valve replacement is recommended in following:
- 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.
Based on above, 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.
ACC/AHA Guidelines- Indications for Surgery for Mitral Regurgitation (DO NOT EDIT) [5]
| “ |
Class I1. 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 IIa1. 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 IIb1. 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 III1. 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 [5].
References
- ↑ 1.0 1.1 1.2 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". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172.
- ↑ Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D; et al. (2006). "Outcome of watchful waiting in asymptomatic severe mitral regurgitation". Circulation. 113 (18): 2238–44. doi:10.1161/CIRCULATIONAHA.105.599175. PMID 16651470.
- ↑ "ACC/AHA 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 (Committee on Management of Patients with Valvular Heart Disease)". Journal of the American College of Cardiology. 32 (5): 1486–588. 1998. PMID 9809971. Retrieved 2011-03-16. Unknown parameter
|month=ignored (help) - ↑ 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.
- ↑ 5.0 5.1 5.2 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.