Indications for Surgical Intervention—Mitral

Regurgitation and Aortic Insufficiency

Ryan HamptonOMS IV

January 2015

Mitral Regurgitation—Indications for Valve Replacement

Considerations• Is MR severe?• Is patient symptomatic?• Is patient a good candidate?• What is Left Ventricular function?• Will mitral valve repair improve quality of

life and mortality?

Severe Chronic Primary MR AND• Symptomatic with LVEF>60%• LVEF between 30-60% irrespective of

symptoms• LVEF <30% only in the event of a primary

mitral apparatus defect Not strong evidence for surgery in

LVEF<30% in the event that MR is secondary to LV dysfunction• No significant symptomatic or mortality

benefit

Mitral Regurgitation—Indications for Valve Replacement

Severe Chronic Primary MR Characteristics (in order of significance)• Defined by doppler echocardiography• Vena contracta width >/= 7mm• Regurgitant orifice >0.40 cm2• Regurgitant volume >/= 60• Regurgitant fraction >/= 50%• Jet area > 40% of left atrial area

Almost always need left atrial or left ventricular enlargement for dx of severe MR (LVEDd >60 mm)

Mitral Regurgitation—Indications for Valve Replacement(ref: 2006 ACC/AHA and 2012 Euro Soc Cardiology)

Mitral Regurgitation—The Asymptomatic Patient

In the absence of symptoms, management decisions are based on echo and LV function

If Severe chronic MR is identified in presence of Normal LV function (EF>60%), patients should be evaluated every 6-12 months with repeat echo with decision for surgery deferred until symptoms present or LV function is compromised

Mitral Regurgitation—LV Dysfunciton

If patient has severely impaired left ventricular function (LVEF<30%), MV repair often does not alter long-term mortality or need for pacemaker

ACC/AHA Guidelines• Surgery if: severe MR in presence of LV

dysfunction is due to primary mitral apparatus abnormality (not functional MR) causing LV impairment

Severe Chronic Primary MR—Factors determining timing of surgery• Severity• Symptoms• LV function• Valve repair feasibility• Presence of AF, Pulmonary HTN• Patient preference/expectation

Mitral Regurgitation—Indications for Valve Replacement(ref: 2006 ACC/AHA and 2012 Euro Soc Cardiology)

Aortic Regurgitation—Indications for Valve Replacement—Class I Evidence

Severe Chronic AR AND:• Symptomatic• Asymptomatic with LVEF<50% at rest• Asymptomatic, LVEF>50% at rest with LVESd>55

mm or LVEDd>75 mm (and sometimes considered with lower thresholds)

• s/p CABG or other valvular or aorta surgery NOT recommended in asymptomatic patient

with LVEF>50% without severe LV dilatation• Periodic echocardiographic monitoring is reasonable

Aortic Regurgitation—Indications for Valve Replacement

Waiting for patient to develop exercise intolerance/dysnea may result in some irreversible LV dysfunction

There, valve replacement for AR in asymptomatic patient with chronic severe AR with LVEF<50% is recommended