Recommendations for Chronic Primary MR Intervention

CORLOERecommendationsComment/Rationale
IBMitral valve surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF greater than 30% (73–75).2014 recommendation remains current.
IBMitral valve surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30% to 60% and/or left ventricular end-systolic diameter [LVESD] ≥40 mm, stage C2) (76–82).2014 recommendation remains current.
IBMitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leaflet (83–99).2014 recommendation remains current.
IBMitral 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 (84,89,95,100–104).2014 recommendation remains current.
IBConcomitant mitral valve repair or MVR is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indications (105).2014 recommendation remains current.
IIaBMitral valve repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and LVESD <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 (101,106–112).2014 recommendation remains current.
IIaC-LDMitral valve surgery is reasonable for asymptomatic patients with chronic severe primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) with a progressive increase in LV size or decrease in ejection fraction (EF) on serial imaging studies (112–115). (Figure 2)NEW: Patients with severe MR who reach an EF ≤60% or LVESD ≥40 have already developed LV systolic dysfunction, so operating before reaching these parameters, particularly with a progressive increase in LV size or decrease in EF on serial studies, is reasonable.
See Online Data Supplement 17 (Updated From 2014 VHD Guideline)
There is concern that the presence of MR leads to progressively more severe MR (“mitral regurgitation begets mitral regurgitation”). The concept is that the initial level of MR causes LV dilatation, which increases stress on the mitral apparatus, causing further damage to the valve apparatus, more severe MR and further LV dilatation, thus initiating a perpetual cycle of ever-increasing LV volumes and MR. Longstanding volume overload leads to irreversible LV dysfunction and a poorer prognosis. Patients with severe MR who develop an EF ≤60% or LVESD ≥40 have already developed LV systolic dysfunction (112–115). One study has suggested that for LV function and size to return to normal after mitral valve repair, the left ventricular ejection fraction (LVEF) should be >64% and LVESD <37 mm (112). Thus, when longitudinal follow-up demonstrates a progressive decrease of EF toward 60% or a progressive increase in LVESD approaching 40 mm, it is reasonable to consider intervention. Nonetheless, the asymptomatic patient with stable LV dimensions and excellent exercise capacity can be safely observed (116).
IIaBMitral valve repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and LVESD <40 mm) in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (pulmonary artery systolic arterial pressure >50 mm Hg) (111,117–123).2014 recommendation remains current.
IIaCConcomitant mitral valve repair is reasonable in patients with chronic moderate primary MR (stage B) when undergoing cardiac surgery for other indications.2014 recommendation remains current.
IIbCMitral valve surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF less than or equal to 30% (stage D).2014 recommendation remains current.
IIbBTranscatheter 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 GDMT for heart failure (HF) (124).2014 recommendation remains current.
III: HarmBMVR 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 (84,89,90,95).2014 recommendation remains current.