Chronic mitral regurgitation treatment

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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 . 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

Primary 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.

The 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.

Secondary Chronic Mitral Regurgitation

The valvular abnormality in chronic secondary MR results from the left ventricular dysfunction. Therefore, the cornerstone of the treatment of patients with chronic secondary MR with decreased ejection fraction is the standard regimen for the treatment of heart failure which includes one or more of the following: beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, or aldosterone antagonists.

Patients with coronary artery disease should receive treatment for their atherosclerosis disease.

Symptomatic patients with chronic severe secondary MR are candidate for cardiac resynchronization therapy with biventricular pacing.

Surgical Therapy for Chronic Mitral Regurgitation

Indications for Surgery in Chronic Primary Mitral Regurgitation

Shown below is an algorithm depicting the indications for mitral valve surgery or period monitoring among patients with chronic primary MR according to the 2014 AHA/ACC guideline for the management of patients with valvular heart disease. Note that when mitral valve surgery is indicated, mitral valve repair is preferred over mitral valve replacement whenever feasible.

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

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.

Mitral Valve Repair vs Mitral Valve Replacement

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 recommend mitral valve repair rather than mitral valve replacement if the anatomy is appropriate, including patients with rheumatic mitral valve disease and mitral valve prolapse (Grade 1C). The procedure should be performed at experienced surgical centers.
• Limited damage to certain areas of the mitral valve leaflets or chordae tendineae.
• 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

Recommendations for Chronic Primary Mitral Valve Regurgitation

Class I

"1. Mitral valve surgery is recommended for symptomatic patients with chronic severe primary mitral regurgitation (stage D) and LVEF greater than 30%. (Level of Evidence: B)"

"2. Mitral valve surgery is recommended for asymptomatic patients with chronic severe primary mitral regurgitation and LV dysfunction (LVEF 30% to 60% and/or LVESD ≥40 mm, stage C2). (Level of Evidence: B)"

"3. Mitral valve repair is recommended in preference to mitral valve replacement (MVR) when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet. (Level of Evidence: B)"

"4. Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished. (Level of Evidence: B)"

"5. Concomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications. (Level of Evidence: B)"

Class IIa

"1. Mitral valve repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and left ventricular end systolic dimension < 40 mm) in whom the likelihood of a successful and durable repair without residual MR is greater than 95% with an expected mortality rate of less than 1% when performed at a heart valve center of excellence. (Level of Evidence: B)"

"2. Mitral valve repair is reasonable for asymptomatic patients with chronic severe non-rheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and left ventricular end systolic dimension <40 mm) in whom there is a high likelihood of a successful and durable repair with: New onset of atrial fibrillation or Resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg). (Level of Evidence: B)"

"3. Concomitant mitral valve repair is reasonable in patients with chronic moderate primary MR (stage B) when undergoing cardiac surgery for other indications. (Level of Evidence: C)"

Class IIb

"1. Mitral valve surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF less than or equal to 30% (stage D). (Level of Evidence: C) "

"2. Mitral valve repair may be considered in patients with rheumatic mitral valve disease when surgical treatment is indicated if a durable and successful repair is likely or when the reliability of long-term anticoagulation management is questionable. (Level of Evidence: B) "

"3. Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal guideline directed medical therapy for heart failure. (Level of Evidence: B) "

Class III

"1. MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless mitral valve repair has been attempted and was unsuccessful. (Level of Evidence: B)"

Recommendations for Chronic Secondary Mitral Valve Regurgitation

Class IIa

"1. Mitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or aortic valve replacement (AVR). (Level of Evidence: C)"

Class IIb

"1. Mitral valve repair or replacement may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT (guideline directed medical therapy) for heart failure. (Level of Evidence: B) "

"2. Mitral valve repair may be considered for patients with chronic moderate secondary MR (stage B) who are undergoing other cardiac surgery. (Level of Evidence: C) "

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Mitral Valve Surgery Indications (DO NOT EDIT)

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)"

Mitral Valve Surgery in Adolescents (DO NOT EDIT)

Class I

"1. MV surgery is indicated in the symptomatic adolescent or young adult with severe congenital MR with NYHA functional class III or IV symptoms. (Level of Evidence: C)"

"2. MV surgery is indicated in the asymptomatic adolescent or young adult with severe congenital MR and LV systolic dysfunction (ejection fraction less than or equal to 0.60). (Level of Evidence: C)"

Class IIa

"1. MV repair is reasonable in experienced surgical centers in the asymptomatic adolescent or young adult with severe congenital MR with preserved LV systolic function if the likelihood of successful repair without residual MR is greater than 90%. (Level of Evidence: B)"

Class IIb

"1. The effectiveness of MV surgery is not well established in asymptomatic adolescent or congenital MR young adult patients with severe and preserved LV systolic function in whom valve replacement is highly likely. (Level of Evidence: C)"