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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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
| 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
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) - ↑ 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.