Guidelines for Intervention in Patients with Chronic Severe Secondary Mitral Regurgitation

International practice guidelines for the care of patients with valvular heart disease were most recently updated in 2017, before the publication of the results of the COAPT and MITRA-FR trials in 2018, and these guidelines were conservative in their recommendations regarding surgery for secondary mitral regurgitation.

American College of Cardiology–American Heart Association
Class IIa recommendation

• Mitral-valve surgery is reasonable for patients with chronic severe secondary mitral regurgitation who are undergoing CABG or aortic-valve replacement. (Level of evidence: C)
• It is reasonable to choose chordal-sparing mitral-valve replacement over repair with a downsized annuloplasty ring if the operation is considered for severely symptomatic patients with chronic severe ischemic mitral regurgitation and persistent symptoms despite the use of maximal doses of guideline-directed medical therapy without adverse effects. (Level of evidence: B)

Class IIb recommendation

• Mitral-valve repair or replacement may be considered for severely symptomatic patients with chronic severe secondary mitral regurgitation who have persistent symptoms despite the use of maximal doses of guideline-directed medical therapy without adverse effects. (Level of evidence: B)

European Society of Cardiology and the European Association for Cardio-Thoracic Surgery

Class I recommendation

• Surgery is indicated in patients with severe secondary mitral regurgitation who are undergoing CABG and who have an LVEF >30%. (Level of evidence: C)

Class IIa recommendation

• Surgery should be considered in symptomatic patients with severe secondary mitral regurgitation and an LVEF <30%, who have an indication for revascularization and evidence of myocardial viability. (Level of evidence: C)

Class IIb recommendation

• When revascularization is not indicated, surgery may be considered in patients with severe secondary mitral regurgitation and an LVEF >30% who remain symptomatic despite the use of maximal doses of medical therapy without adverse effects (and cardiac resynchronization therapy if indicated) and have a low risk of surgery-related complications or death. (Level of evidence: C)
• When revascularization is not indicated and the risk of surgery-related complications or death is not low, a percutaneous edge-to-edge procedure may be considered in patients with severe secondary mitral regurgitation and an LVEF >30% who remain symptomatic despite the use of maximal doses of medical therapy without adverse effects (and cardiac resynchronization therapy, if indicated) and who are found to have suitable valve morphologic characteristics on echocardiography, if the heart team thinks there is a reasonable chance for clinical improvement. (Level of evidence: C)
• In patients with severe secondary mitral regurgitation and an LVEF <30% who remain symptomatic despite the use of maximal doses of medical therapy without adverse effects (and cardiac resynchronization therapy if indicated) and who have no option for revascularization, the heart team may consider a percutaneous edge-to-edge procedure or valve surgery after careful evaluation for a left ventricular assist device or heart transplantation according to individual patient characteristics. (Level of evidence: C)

* The class of recommendation indicates the strength of the recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk. In general, a class I recommendation indicates that the intervention is indicated or useful and should be performed. A class IIa recommendation implies that the intervention is reasonable and can be effective, whereas a class IIb recommendation implies that the usefulness or effectiveness of the intervention is less certain. The guidelines differ with respect to methods and language, although the recommendations are directionally concordant. The level of evidence rates the quality of scientific evidence that supports the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources. Level B evidence may derive from randomized trials, observational studies, and registries, and it is considered to be of moderate quality. Level C evidence relies on limited data, expert opinion, or both. These guideline recommendations reflect the strength of the evidence base in existence in 2017.

CABG denotes coronary-artery bypass grafting, and LVEF left ventricular ejection fraction.

 

References:

1. O’Gara PT, Mack MJ. Secondary Mitral Regurgitation. N Engl J Med. 2020 Oct 8;383(15):1458-1467. [Medline]
2. Deferm S, Bertrand PB, Verbrugge FH, Verhaert D, Rega F, Thomas JD, Vandervoort PM. Atrial Functional Mitral Regurgitation: JACC Review Topic of the Week. J Am Coll Cardiol. 2019 May 21;73(19):2465-2476. [Medline]
3. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, Hahn RT, Han Y, Hung J, Lang RM, Little SH, Shah DJ, Shernan S, Thavendiranathan P, Thomas JD, Weissman NJ. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017 Apr;30(4):303-371. [Medline]

 

Created Dec 22, 2020.