Recommendations for Secondary MR Intervention

CORLOERecommendationsComment/Rationale
IIaCMitral valve surgery is reasonable for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR.2014 recommendation remains current.
IIaB-RIt is reasonable to choose chordal-sparing MVR over downsized annuloplasty repair if operation is considered for severely symptomatic patients (NYHA class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite GDMT for HF (69,70,125,127,130–139).NEW: An RCT has shown that mitral valve repair is associated with a higher rate of recurrence of moderate or severe MR than that associated with mitral valve replacement (MVR) in patients with severe, symptomatic, ischemic MR, without a difference in mortality rate at 2 years’ follow-up.
See Online Data Supplement 18 (Updated From 2014 VHD Guideline)
In an RCT of mitral valve repair versus MVR in 251 patients with severe ischemic MR, mortality rate at 2 years was 19.0% in the repair group and 23.2% in the replacement group (p=0.39) (70). There was no difference between repair and MVR in LV remodeling. The rate of recurrence of moderate or severe MR over 2 years was higher in the repair group than in the replacement group (58.8% versus 3.8%, p<0.001), leading to a higher incidence of HF and repeat hospitalizations in the repair group (70). The high mortality rate at 2 years in both groups emphasizes the poor prognosis of secondary MR. The lack of apparent benefit of valve repair over valve replacement in secondary MR versus primary MR highlights that primary and secondary MR are 2 different diseases (69,125,127,130–139).
IIbBMitral 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 for HF (125,127,130–140).2014 recommendation remains current.
IIbB-RIn patients with chronic, moderate, ischemic MR (stage B) undergoing CABG, the usefulness of mitral valve repair is uncertain (71,72).MODIFIED: LOE updated from C to B-R. The 2014 recommendation supported mitral valve repair in this group of patients. An RCT showed no clinical benefit of mitral repair in this population of patients, with increased risk of postoperative complications.
See Online Data Supplement 18 (Updated From 2014 VHD Guideline)
In an RCT of 301 patients with moderate ischemic MR undergoing CABG, mortality rate at 2 years was 10.6% in the group undergoing CABG alone and 10.0% in the group undergoing CABG plus mitral valve repair (HR in the combined-procedure group = 0.90; 95% CI: 0.45 to 1.83; p=0.78) (71). There was a higher rate of moderate or severe residual MR in the CABG-alone group (32.3% versus 11.2%; p<0.001), even though LV reverse remodeling was similar in both groups (71). Although rates of hospital readmission and overall serious adverse events were similar in the 2 groups, neurological events and supraventricular arrhythmias were more frequent with combined CABG and mitral valve repair. Thus, only weak evidence to support mitral repair for moderate secondary MR at the time of other cardiac surgery is currently available (71,72).