Chronic primary MR: Management of severe MR

ERO: effective regurgitant orifice; LA: left atrium; LV: left ventricular; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic dimension; MELD: Model for End-Stage Liver Disease; MR: mitral regurgitation; STS: Society of Thoracic Surgeons; TEER: transcatheter edge-to-edge mitral repair.

* Severe MR is defined as a central jet MR >40% LA or holosystolic eccentric jet MR, vena contracta ≥0.7 cm, regurgitant volume ≥60 mL, regurgitant fraction ≥50%, ERO ≥0.40 cm, or angiographic grade 3 to 4+.

¶ Prohibitive risk for mitral valve surgery is determined by a multidisciplinary heart team (including a cardiac surgeon experienced in mitral valve surgery and a cardiologist experienced in mitral valve disease) due to the presence of one or more of the following surgical risk factors: 30-day STS-predicted operative mortality risk score of ≥8% for patients deemed likely to undergo mitral valve replacement or ≥6% for patients deemed likely to undergo mitral valve repair, porcelain aorta (extensively calcified ascending aorta), frailty (assessed by in-person cardiac surgeon consultation), hostile chest (conditions that make a sternotomy or thoracotomy for valve surgery prohibitively hazardous), severe liver disease/cirrhosis (MELD Score >12), severe pulmonary hypertension (systolic pulmonary artery pressure >2/3 systemic pressure), extenuating comorbidities (eg, right ventricular dysfunction with severe tricuspid regurgitation, major bleeding diathesis, internal mammary artery graft at high risk of injury).

Δ Medical management involves treatment for heart failure and/or LV systolic dysfunction.

◊ Monitoring includes periodic history (to assess symptoms), physical examination, and echocardiography. Echocardiography is performed every 6 to 12 months in patients with severe MR.

§ A patient in this setting is not generally a candidate for mitral valve intervention until symptoms or LV systolic dysfunction develops. However, if the patient undergoes cardiac surgery for another indication (eg, coronary artery bypass graft surgery), then mitral valve surgery (generally repair) may be performed during the same surgical procedure.