Sandbox Rim

Abbreviations: LVEF: left ventricular ejection fraction; LVESD: left ventricular end systolic diameter; MR: mitral regurgitation; PASP: Pulmonary artery systolic pressure

Primary MR

What is the severity of MR?

Severe MR ❑ Severe MVP with loss of coaptation ❑ RHD with loss of central coaptation ❑ Left ventricular dilation ❑ Regurgitation fraction ≥ 50% ❑ Regurgitation volume ≥ 60ml ❑ Effective regurgitation orifice ≥ 0.4cm² ❑ Vena contracta ≥ 0.7cm

Progressive MR (Stage B) ❑ Severe MVP with normal coaptation ❑ RHD with normal coaptation ❑ No Left ventricular dilation ❑ Regurgitation fraction < 50% ❑ Regurgitation volume < 60ml ❑ Effective regurgitation orifice < 0.4cm² ❑ Vena contracta < 0.7cm

Is the patient symptomatic?

Yes (Stage D)

No (Stage C)

Is the LVEF>30%?

LVEF 30-60% OR LVESD≥40 mm (Stage C2)

LVEF>60% AND LVESD<40 mm (Stage C1)

New onset atrial fibrillation OR PASP>50 mmHg (Stage C1)

Is the likelihood of success for the valve repair >95% and the expected mortality <1%?

No

Yes

Yes

No

Mitral valve surgery (Class IIb)

Mitral valve surgery (Class I)

Mitral valve repair (Class IIa)

Periodic monitoring

Periodic monitoring