Table 15

Summary of Recommendations for Chronic Primary MR

RecommendationsCORLOEReferences
MV surgery is recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF >30%IB(156,179)
MV surgery is recommended for asymptomatic patients with chronic severe primary MR and LV dysfunction (LVEF 30%–60% and/or LVESD ≥40 mm, stage C2)IB(150–153,180–182)
MV repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR limited to the posterior leafletIB(155,183–198)
MV 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 accomplishedIB(195–197,199–203)
Concomitant MV repair or replacement is indicated in patients with chronic severe primary MR undergoing cardiac surgery for other indicationsIB(204)
MV 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 >95% with an expected mortality rate of <1% when performed at a Heart Valve Center of ExcellenceIIaB(149,203,205–209)
MV repair is reasonable for asymptomatic patients with chronic severe nonrheumatic primary MR (stage C1) and preserved LV function in whom there is a high likelihood of a successful and durable repair with 1) new onset of AF or 2) resting pulmonary hypertension (PA systolic arterial pressure >50 mm Hg)IIaB(154,205,210–215)
Concomitant MV repair is reasonable in patients with chronic moderate primary MR (stage B) undergoing cardiac surgery for other indicationsIIaCN/A
MV surgery may be considered in symptomatic patients with chronic severe primary MR and LVEF ≤30% (stage D)IIbCN/A
MV 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 if the reliability of long-term anticoagulation management is questionableIIbB(194,202,203)
Transcatheter MV repair may be considered for severely symptomatic patients (NYHA class III/IV) with chronic severe primary MR (stage D) who have a reasonable life expectancy but a prohibitive surgical risk because of severe comorbiditiesIIbB(216)
MVR should not be performed for treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessfulIII: HarmB(195–198)

AF indicates atrial fibrillation; COR, Class of Recommendation; LOE, Level of Evidence; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation; MV, mitral valve; MVR, mitral valve replacement; N/A, not applicable; NYHA, New York Heart Association; and PA, pulmonary artery.