Guidance Issued on Management of Mitral Regurgitation

Patrice Wendling

October 24, 2017

DALLAS, TX — The American College of Cardiology (ACC) has released an expert consensus decision pathway document on the management of mitral regurgitation (MR)[1].

Based on the 2014 American Heart Association/ACC guidelines for the management of valvular heart disease[2] and its 2017 focused update[3], the document strives to help clinicians "interpret and use those guidelines in a more direct way," Dr Vinay Badhwar (West Virginia University, Morgantown), one of the writing committee vice chairs, told | Medscape Cardiology.

Specifically, he said the document focuses on "how one makes the diagnosis; once the diagnosis is made how one categorizes the diagnosis based on pathoanatomy; and once [the diagnosis is] categorized how one navigates the guidelines and clinical equipoise to determine the best course of treatment. That in summary is exactly what this expert consensus document aims to achieve."

The committee, chaired by Dr Patrick O'Gara (Brigham and Women's Hospital, Boston), notes that a recent ACC-commissioned survey identified "major knowledge and practice gaps," including failure to identify clinically significant MR on physical exam, failure to distinguish primary from secondary MR, poor quality and incomplete echocardiographic assessment and reporting, and lack of awareness of guideline-based treatment recommendations.

The consensus document, published online October 18, 2016 in the Journal of the American College of Cardiology, details each step in the management pathway through a series of clinical scenarios, tables, charts, and algorithms. For example, there is a chart on the suggested qualitative and quantitative parameters for standardized echocardiography reporting and a decision tree for distinguishing primary from secondary MR.

Key points of the document are:

  • Once MR is recognized, its etiology, mechanism, and severity should be defined using quantitative echocardiography and other testing as indicated.

  • Standardized echocardiographic reporting and timely access to accurate information are critical for effective patient management.

  • The prognostic, evaluative, and management differences between primary and secondary MR should be recognized.

  • A heart-valve team consensus treatment recommendation should be discussed with the patient and family to enable shared decision-making.

  • The indications for and techniques utilized in surgical treatment of primary and secondary MR differ. Evidence-based medical and device therapies should be optimized in patients with secondary MR before surgery is attempted.

  • Mitral-valve surgery is indicated for symptomatic (stage D) or asymptomatic (stage C2) patients with primary severe MR and EF >30%.

  • The main goals of mitral-valve repair are to restore leaflet coaptation depth to >5 mm, stabilize and remodel the annulus, restore normal leaflet motion, and eliminate MR.

The document also includes an algorithm for how and when to refer patients to a comprehensive valve center.

"I want to be very clear that this document does not suggest that every patient with MR needs to go to an experienced surgeon and center. In fact, it should be tailored to those of augmented complexity," Badhwar said.

He added, "Many if not all surgeons should have the technical experience to repair straightforward mitral-valve prolapse such as P2 flail. I use the analogy every day; if a surgeon can do a coronary bypass with 7–0 or 8–0 proline under their loops they can do a small resection of P2 and put a ring on quite readily."

Specifically, the document states that referral for repair "should be considered for asymptomatic stage C1 patients, patients in whom complex repair is required, and patients who wish to pursue a minimally invasive or robotic approach."

The document does not directly come up with indications and contraindications for transcatheter treatment of MR but includes an algorithm for determining eligibility for transcatheter edge-to-edge repair. The mitral clip is currently the only approved transcatheter repair system in the US, and its use is restricted to symptomatic patients with primary, severe MR who are poor surgical candidates.

Other mitral-valve repair and replacement systems are under investigation, but currently transcatheter mitral-valve replacement (TMVR) must be performed only within an early feasibility or clinical trial, Badhwar said.

"I imagine this document will be updated once an indication is met" for TMVR, he said, "But it will likely be a minimum of 2 years before we have the appropriate signals for an indication, at the earliest."

Badhwar reported institutional relationships with On-X Technologies, Edwards Lifesciences, and Abbott Vascular/Tendyne. Disclosures for the rest of the writing committee are listed in the paper.

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