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2021 ACC/AHA Guidelines on Valvular Heart Disease

The American College of Cardiology (ACC) and American Heart Association (AHA) released their updated recommendations on managing valvular heart disease in December 2020.^{[28, 29]}Key messages are outlined below.

Valvular heart disease (VHD) stages (stages A-D) in patients should be classified based on symptoms, valve anatomy, severity of valve dysfunction, and response of the ventricle and pulmonary circulation.

When evaluating patients with VHD, findings from the history and physical examination (PE) should be correlated with those from noninvasive testing (ie, electrocardiography [ECG], chest x-ray, transthoracic echocardiography [TTE]). If conflict exists between results on the PE and that of initial noninvasive studies, consider obtaining further noninvasive (computed tomography [CT], cardiac magnetic resonance imaging [CMRI], stress testing) or invasive (transesophageal echocardiography [TEE], cardiac catherization) studies to decide the optimal treatment strategy.

In the setting of VHD and atrial fibrillation (AF) (except for patients with rheumatic mitral stenosis [MS] or a mechanical prosthesis), the decision to use oral anticoagulation with either a vitamin K antagonist (VKA) or a non-VKA anticoagulant to prevent thromboembolic events should be a shared decision-making process based on the CHA2DS2-VASc score (congestive heart failure [CHF], hypertension, age ≥75 years, diabetes mellitus, previous stroke/transient ischemic attack/thromboembolic event, vascular disease, age 65-74 years, sex). Oral anticoagulation with a VKA should be given to those with rheumatic MS or a mechanical prosthesis and AF.

All those with severe VHD under consideration for valve intervention should be evaluated by a multidisciplinary team, either with a referral or in consultation with a primary or comprehensive valve center.

Indications for intervention for valvular regurgitation are symptomatic relief and prevention of the irreversible long-term consequences of left ventricular volume overload. Lowered thresholds for intervention than they were previously are owing to more durable treatment options and lower procedural risks.

A mitral transcatheter edge-to-edge repair benefits patients with severely symptomatic primary mitral regurgitation (MR) who are at high or prohibitive surgical risk, as well as benefits a select subset of patients with secondary MR who remain severely symptomatic despite guideline-directed management and heart failure therapy.

Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.

Go to 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: Developed by the Task Force on cardiac pacing and cardiac resynchronization therapy of the European Society of Cardiology (ESC) with the special contribution of the European Heart Rhythm Association (EHRA) for full details.

2021 ESC/EACTS Management of Valvular Heart Disease (VHD) Clinical Practice Guidelines

Guidelines for the management of patients with valvular heart disease (VHD) were published in August 2021 by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS),^[30]including the following recommendations on mitral valve disease:

Surgery (mitral valve repair) is recommended for symptomatic patients with severe primary mitral regurgitation who are operable and not high-risk and for asymptomatic patients with LV dysfunction.
In cases of severe secondary mitral regurgitation, valve surgery/intervention is recommended only for patients who remain symptomatic despite guideline-directed medical treatment (GDMT; including cardiac resynchronization therapy [CRT] if indicated).

2017 ACC/AHA Guidelines

In 2017, the American College of Cardiology Task Force on Expert Consensus Pathways published their updated recommendations for mitral regurgitation (MR), which primarily consisted of those for chronic primary and chronic secondary MR and are summarized below.^[31]In general, the 2014 recommendations remain current (see below, under "2014 ACC/AHA guidelines"), with a few updated recommendations.

Chronic primary MR interventions

Class IIa (moderate strength, with limited data)

Mitral valve surgery is reasonable for asymptomatic patients with chronic severe primary MR (stage C1) and preserved left ventricular (LV) function (LV ejection fraction [LVEF] >60% and LV end-systolic dimension [LVESD] < 40 mm) with a progressive increase in LV size or decrease in EF on serial imaging studies.

Chronic secondary MR interventions

Class IIa (moderate strength, moderate quality from randomized trials)

Chordal-sparing MVR is a reasonable selection over downsized annuloplasty repair if the procedure is considered for severely symptomatic patients (New York Heart Association [NYHA] class III to IV) with chronic severe ischemic MR (stage D) and persistent symptoms despite guideline-directed medical therapy (GDMT) for heart failure (HF).

Class IIb (weak, moderate quality from randomized trials)

In patients with chronic, moderate, ischemic MR (stage B) undergoing CABG, the usefulness of mitral valve repair is uncertain.

2017 ESC/EACTS Guidelines

The European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) published 2017 updated guidelines to their 2014 recommendations for the management of valvular heart disease.^[32]

Class I (recommended/indicated; level of evidence that is the consensus opinion of experts and/or small studies, retrospective studies, registries)

Coronary angiography is recommended for evaluating moderate to severe secondary MR.

Class IIa (should be considered; data derived from a single randomized clinical trial or large nonrandomized studies)

Non-vitamin K antagonist oral anticoagulants (NOACs) should be considered as an alternative to vitamin K antagonists (VKAs) in patients with aortic stenosis, aortic regurgitation and MR presenting with atrial fibrillation.

Indications for intervention in severe primary MR

Class I (recommended/indicated)

The preferred technique should be mitral valve repair when the results are expected to last. (Level of evidence: consensus opinion of experts and/or small studies, retrospective studies, registries)

Surgery is indicated in the following individuals (data derived from a single randomized clinical trial or large nonrandomized studies):

Symptomatic patients with LVEF over 30%
Asymptomatic patients with LV dysfunction (LVESD ≥45 mm and/or LVEF ≤60%)

Class IIa (should be considered)

Surgery should be considered in the following patients:

Asymptomatic patients with preserved LV function (LVESD < 45 mm and LVEF >60%) and atrial fibrillation secondary to MR or pulmonary hypertension (systolic pulmonary pressure at rest >50 mmHg) (Data derived from a single randomized clinical trial or large nonrandomized studies.)
Asymptomatic patients with preserved LVEF (>60%) and LVESD of 40-44 mm when a durable repair is likely, surgical risk is low, the repair is performed in a heart valve center, and at least one of the following findings is present (consensus opinion of experts and/or small studies, retrospective studies, registries): flail leaflet or presence of significant left atrial (LA) dilatation (volume index ≥60 mL/m ² BSA) in sinus rhythm

Mitral valve repair should be considered in symptomatic patients with severe LV dysfunction (LVEF < 30% and/or LVESD >55 mm) refractory to medical therapy when the likelihood of successful repair is high and comorbidity low. (Consensus opinion of experts and/or small studies, retrospective studies, registries)

Class IIb (may be considered consensus opinion of experts and/or small studies, retrospective studies, registries)

Mitral valve replacement may be considered in symptomatic patients with severe LV dysfunction (LVEF < 30% and/or LVESD >55 mm) refractory to medical therapy when the likelihood of successful repair is low and comorbidity low.

Percutaneous edge-to-edge procedure may be considered in patients with symptomatic severe primary MR who fulfil the echocardiographic criteria of eligibility and are judged inoperable or at high surgical risk by the heart team, avoiding futility.

Indications for mitral valve intervention in chronic secondary MR

Class I (should be considered; recommended/indicated; level of evidence that is the consensus opinion of experts and/or small studies, retrospective studies, registries)

Surgery is indicated in patients with severe secondary MR undergoing CABG and an LVEF over 30%.

Class IIa (should be considered consensus opinion of experts and/or small studies, retrospective studies, registries)

Surgery should be considered in symptomatic patients with severe secondary MR, an LVEF below 30% but with an option for revascularization and evidence of myocardial viability.

Class IIb (may be considered consensus opinion of experts and/or small studies, retrospective studies, registries)

When revascularization is not indicated, surgery may be considered in patients with severe secondary MR and an LVEF above 30% who remain symptomatic despite optimal medical management (including cardiac resynchronization therapy [CRT] if indicated) and have a low surgical risk.

When revascularization is not indicated and the surgical risk is not low, a percutaneous edge-to-edge procedure may be considered in patients with severe secondary MR and an LVEF over 30% who remain symptomatic despite optimal medical management (including CRT if indicated) and who have a suitable valve morphology by echocardiography, avoiding futility.

In patients with severe secondary MR and an LVEF below 30% who remain symptomatic despite optimal medical management (including CRT if indicated) and who have no option for revascularization, the heart team may consider a percutaneous edge-to-edge procedure or valve surgery after careful evaluation for a ventricular assist device or heart transplant according to each individual patient's characteristics.

2016 AATS Guidelines

The 2016 American Association for Thoracic Surgery (AATS) updated recommendations for ischemic mitral valve regurgitation (IMR) are outlined below.^[33]

Mitral valve replacement is reasonable in patients with severe IMR who remain symptomatic despite Guideline-directed medial and cardiac device therapy, and who have a basal aneurysm/dyskinesis, significant leaflet tethering, and/or severe left ventricle dilation (left ventricular end diastolic diameter [LVEDD] > 6.5 cm).

Mitral valve repair with an undersized complete rigid annuloplasty ring may be considered in patients with severe IMR who remain symptomatic despite Guideline-directed medical and cardiac device therapy and who do not have a basal aneurysm/dyskinesis, significant leaflet tethering, or severe left ventricle enlargement.

In patients with moderate IMR undergoing CABG, mitral valve repair with an undersized complete rigid annuloplasty ring may be considered.

Mitral valve repair for IMR is performed with complete preservation of both anterior and posterior leaflet chords.

Mitral valve repair for IMR is performed with small, undersized, complete rigid annuloplasty ring.

2014 ACC/AHA Guidelines

In 2014, the ACC/American Heart Association (ACC/AHA) released a revision to its 2008 guidelines for the management of patients with valvular heart disease (VHD); and the ESC/EACTS issued a revision of its 2007 guidelines in 2012.^{[1, 13]}

The ACC/AHA guidelines classify progression of chronic mitral regurgitation (MR) into 4 stages (A to D) as follows^[13]:

Stage A: At risk of MR
Stage B: Asymptomatic with progressive MR
Stage C: Asymptomatic with severe MR; stage C1 (left [LV] or right ventricle [RV] remains compensated) or stage C2 (decompensation of LV or RV)
Stage D: Symptomatic with severe MR

The guidelines note that when assessing chronic MR, it is important to distinguish between chronic primary (degenerative) MR and chronic secondary (functional) MR, as these conditions have more differences than similarities. The staging criteria is summarized in the table below.^[13]

Table 1. Stages of Progression of Chronic Mitral Regurgitation (Open Table in a new window)

Stage	Valve Anatomy	Valve Hemodynamics*	Hemodynamic Consequences	Symptoms
A: Primary MR	Mild MV prolapse with normal coaptation Mild valve thickening and leaflet restriction	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	None	None
A: Secondary MR	Normal valve leaflets, chords and annulus in patient with CAD or cardiomyopathy	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	Normal or mildly dilated LV with infarction or ischemia regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
B: Primary MR	Severe MV prolapse with normal coaptation Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE	Central jet MR area 20-40% LA or late systolic eccentric jet MR Vena contracts < 0.7 cm Regurgitant volume < 60 mL Regurgitant fraction < 50% ERO < 0.40 cm ² Angiographic grade 1-2+	Mild LA enlargement No LV enlargement Normal Pulmonary pressure	None
B: Secondary MR	Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets	Regurgitant volume < 30 mL Regurgitant fraction < 50% ERO < 0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
C: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm ² Angiographic grade 3-4+	Moderate to severe LA enlargement LV enlargement Pulmonary hypertension may be present Stage C1: LVEF >60% and LVESD < 40 mm Stage C2: LVEF ≤60% and LVESD ≥40 mm	None
C: Secondary MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
D: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm ² Angiographic grade 3-4+	Moderate or severe LA enlargement LV enlargement Pulmonary hypertension present	Decreased exercise tolerance Exertional dyspnea
D: Secondary MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	HF symptoms due to MR persist after revascularization and medical therapy Decreased exercise tolerance Exertional dyspnea
*Several criteria are provided but not all criteria for each category will be present. Severity of mild, moderate, or serve is dependent on data quality and integration with other clinical evidence. ^†In secondary MR, true ERO is underestimated due to the crescentic shape of the proximal convergence
CAD = coronary heart disease; ERO = effective regurgitation orifice; HF = heart failure; IE = infective endocarditis; LA = left atrium; LV = left ventricular; LVEF = left ventricular ejection factor; LVESD = left ventricular end-systolic dimension; MR = mitral regurgitation; MV = mitral valve; TTE = transthoracic echocardiography.

Both guidelines require intervention decisions for severe valvular heart disease (VHD) be based on an individual risk-benefit analysis. Improved prognosis should outweigh the risk of intervention and potential late consequences, particularly complications related to prosthetic valves.^{[1, 13]}

Recognizing the known limitations of the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and the STS (Society of Thoracic Surgeons) score, the ACC/AHA guidelines suggest using STS plus three additional indicators: frailty (using accepted indices), major organ system compromise not to be improved postoperatively, and procedure-specific impediment when assessing risk.^[13]

Diagnosis

The ESC/EACTS echocardiographic criteria for the definition of severe MR are as follows^[1]:

Flail leaflet/ruptured papillary muscle/large coaptation defect
Very large color flow central jet or eccentric jet adhering, swirling, and reaching the posterior wall of the LA
Dense/triangular continuous-wave signal of regurgitant jet
Large flow convergence zone

ACC/AHA class I indications for transthoracic echocardiography (TTE) are as follows^[13]:

Baseline evaluation for LV size and function, right ventricular (RV) and LA size, pulmonary artery pressure, and severity of MR
Determining the etiology of MR
Annual or semiannual surveillance of LV ejection fraction (LVEF) and end-systolic dimension in asymptomatic patients with moderate-to-severe MR
Evaluation of the MV apparatus and LV function after a change in signs or symptoms
Evaluation of LV size and function and MV hemodynamics in the initial evaluation after MV replacement (MVR) or MV repair

ACC/AHA class I indications for serial TTE are as follows^[13]:

Asymptomatic patients with mild MR and no evidence of LV enlargement, LV dysfunction, or pulmonary hypertension: Yearly observation; serial TTE is not indicated
Patients with moderate MR: Yearly TTE
Asymptomatic patients with severe MR: TTE and clinical evaluation every 6-12 months to assess symptoms and development of LV dysfunction

ACC/AHA class I indications for transesophageal echocardiography (TEE) are as follows^[13]:

Assessment of etiology of severe MR in patients for whom surgery is recommended to determine the feasibility of MV repair
Evaluation of MV and associated structures when TTE is nondiagnostic

Acute Mitral Regurgitation

The ACC/AHA guidelines note that it may be difficult to diagnose severe acute MR with TTE due to narrow eccentric jets of MR, tachycardia, and early equalization of LV and LA pressures. In cases where TTE is nondiagnostic but the suspicion of severe acute MR persists, enhanced MV imaging with TEE is recommended. In patients with sudden acute and hemodynamic instability after myocardial infarction (MI) with hyperdynamic LV function and no other cause for the deterioration, TEE should be performed as soon as possible, looking for severe MR due either to a papillary muscle or chordal rupture.^[13]

The guidelines suggest vasodilator therapy to improve hemodynamic compensation in acute MR; however, use of vasodilators is often limited by systemic hypotension that is exacerbated when peripheral resistance is decreased. Intra-aortic balloon counterpulsation can be utilized for achieving hemodynamic stability until definitive mitral surgery can be performed. The use of a percutaneous circulatory assist device may also be effective to stabilize a patient with acute hemodynamic compromise before operation.^[13]

Prompt MV surgery is recommended for treatment of the symptomatic patient with acute severe primary MR. In cases of ruptured chordae tendineae, mitral repair is usually feasible and preferred over valve replacement, and the timing of surgery can be determined by the patient’s hemodynamic status. If infectious endocarditis (IE) is the cause of severe symptomatic MR, earlier surgery is generally preferred because of better outcomes over medical therapy. However, this strategy should also be tempered by the patient’s overall condition.^[13]

Primary Mitral Regurgitation

The ACC/AHA and ESC/EACTS guidelines agree that MV surgery for symptomatic patients with chronic severe primary MR (stage D) and LVEF above 30% is a class I recommendation.^{[1, 13]}

The ACC/AHA guidelines also provide a class I recommendation for MV surgery for asymptomatic patients with chronic severe primary MR (stage C2) and an LVEF of 30%–60% and/or an LVESD of at least 40 mm,^[13]whereas the ESC/EACTS uses a benchmark of an LVEF above 30% and an LVESD below 55 mm for its class I recommendation.^[1]

The ACC/AHA also gives class I recommendations for MV repair in preference to MVR in the following^[13]:

Severe primary MR limited to the posterior leaflet
Severe primary MR involving the anterior leaflet or both leaflets and a successful and durable repair can be accomplished

The ECS/EACTS guidelines prefer MV repair when a durable repair can be expected.^[1]

Additional ACC/AHA recommendations for interventions for primary MR include the following^[13]:

Concomitant MV repair or replacement for patients undergoing other cardiac surgery (class I for severe primary MR; class IIa for moderate primary MR)
MV repair in asymptomatic patients with chronic severe primary MR (stage C1) with LVEF above 60% and LVESD below 40 mm:
- When the likelihood of a successful and durable repair is over 95% and the expected operational mortality rate is less than 1% and the procedure is performed at a heart valve center of excellence (class IIa)
- When the likelihood of a successful and durable repair is high and there is new onset of atrial fibrillation (AF) or resting pulmonary hypertension (class IIa)
Medical therapy for systolic dysfunction in symptomatic patients with chronic primary MR (stage D) and LVEF below 60% in whom surgery is not contemplated (class IIa)
Consider MV surgery in symptomatic patients with chronic severe primary MR and LVEF of 30% or less (class IIb)
Consider MV repair in patients with rheumatic MV disease if a durable and successful repair is likely or when reliability of long-term coagulation management is not feasible (class IIb)
Consider transcatheter MV repair for severely symptomatic patients (New York Heart Association [NYHA] functional class III-IV) with chronic severe primary MR (stage D) who have favorable anatomy and a reasonable life expectancy but have prohibitive surgical risk due to severe comorbidities and remain severely symptomatic despite optimal GDMT for HF (class IIb)
MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful (class III).

In general, the ESC/EACTS guidelines are in alignment with the AHA/ACC recommendations.^[1]

Secondary Mitral Regurgitation

The ACC/AHA class I recommendations for management of secondary MR include the following^[13]:

Patients with chronic secondary MR and HF with reduced LVEF should receive standard medical therapy for HF including angiotensin-converting enzyme (ACE) inhibitors (ACEIs), angiotensin-receptor blockers (ARBs), beta blockers, and/or aldosterone antagonists.
Cardiac resynchronization therapy (CRT) with biventricular pacing or symptomatic patients with chronic severe secondary MR who meet the indications for device therapy.

Both the ACC/AHA and ESC/EACTS guidelines recommend MV surgery for patients with chronic severe secondary MR (stages C and D) who are undergoing CABG or AVR (class IIa, ACC/AHA; class I, ESC/EACTS).^{[1, 13]}The ESC/EACTS guidelines also recommend surgery be considered for patients with moderate MR undergoing CABG (class IIa).^[1]

Additional ACC/AHA recommendations include the following^[13]:

Consider MV repair or replacement for severely symptomatic patients (NYHA class III to IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal medical therapy for HF (class IIb).
Consider MV repair for patients with chronic moderate secondary MR (stage B) who are undergoing other cardiac surgery (class IIb).

Infective Endocarditis

Both the AHA and ESC released updated guidelines for the management of IE in 2015.^{[34, 35]}Major recommendations from the AHA for the management of IE are summarized below^{[13, 35]}:

Class I

The Modified Duke Criteria should be used in evaluating a patient with suspected IE. (Level of evidence: B)

At least 3 sets of blood cultures from different venipuncture sites should be obtained, with the first and last samples drawn at least 1 hour apart. (Level of evidence: A)

TTE should be performed in all cases of suspected IE. (Level of evidence: B)

TEE should be performed if initial TTE images are negative or inadequate in patients for whom there is an ongoing suspicion for IE or when there is concern for intracardiac complications in patients with an initial positive TTE. (Level of evidence: B)

If there is a high suspicion of IE despite an initial negative TEE, then obtain a repeat TEE in 3 to 5 days or sooner if clinical findings change. (Level of evidence: B)

Repeat TEE should be performed after an initially positive TEE if clinical features suggest a new development of intracardiac complications. (Level of evidence: B)

Before being considered for outpatient therapy, patients with IE should first be evaluated and stabilized in the hospital. (Level of evidence: C)

Appropriate antibiotic therapy should be initiated and continued after blood cultures are obtained, with guidance from antibiotic sensitivity data and infectious disease consultants. (Level of Evidence: B)

Patients selected for outpatient parenteral antibiotic therapy (OPAT) should be at low risk for the complications of IE, the most frequent of which are heart failure and systemic emboli. (Level of evidence: C)

Surgery should be performed before completion of a full therapeutic course of antibiotics in patients with the following:

IE and valve dysfunction resulting in symptoms of HF (Level of evidence: B)
IE caused by fungi or highly resistant organisms (eg, vancomycin-resistant Enterococcus, multidrug-resistant Gram-negative bacilli) (Level of evidence: B)
IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions (Level of evidence: B)
Persistent bacteremia or fevers lasting longer than 5 to 7 days after the onset of appropriate antimicrobial therapy (Level of evidence: B)

Valve repair rather than replacement should be performed when feasible. (Level of evidence: C)

Months to years after completion of medical therapy for IE, patients should have ongoing observation for and education about recurrent infection and delayed onset of worsening valve dysfunction. (Level of evidence: C)

Class III

Patients should not receive antibiotics before blood cultures are obtained for unexplained fever. (Level of evidence: C)

Antimicrobial therapy should not be initiated for the treatment of undefined febrile illnesses unless the patient’s condition (eg, sepsis) warrants it. (Level of evidence: C)

Resources

For more information, please go to Aortic Stenosis, Aortic Regurgitation, Mitral Stenosis, Mitral Regurgitation, and Tricuspid Regurgitation.

For more Clinical Practice Guidelines, please go to Guidelines.

Medication

[Guideline] Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012 Oct. 33(19):2451-96. [QxMD MEDLINE Link]. [Full Text].
O'Riordan M. FDA approves MitraClip for degenerative MR. Heartwire from Medscape. October 25, 2013. Available at http://www.medscape.com/viewarticle/813216. Accessed: October 28, 2013.
Abbott. Abbott's first-in-class MitraClip device now available for U.S. patients [press release]. October 25, 2013. Available at http://www.abbott.com/press-release/abbotts-firstinclass-mitraclip-device-now-available-for-us-patients.htm. Accessed: October 28, 2013.
Sharma A, Goel S, Agrawal S. Percutaneous mitral valve interventions and heart failure. Adv Exp Med Biol. 2018. 1067:271-85. [QxMD MEDLINE Link].
Crousillat DR, Wood MJ. Valvular heart disease and heart failure in women. Heart Fail Clin. 2019 Jan. 15(1):77-85. [QxMD MEDLINE Link].
Eleid MF, Thaden JJ. Mitral annulus enlargement in mitral regurgitation: look to the north. Int J Cardiol. 2019 Jan 1. 274:261-2. [QxMD MEDLINE Link]. [Full Text].
Kim JH, Lee SH, Joo HC, et al. Effect of recurrent mitral regurgitation after mitral valve repair in patients with degenerative mitral regurgitation. Circ J. 2017 Dec 25. 82(1):93-101. [QxMD MEDLINE Link].
Rossi A, Dini FL, Faggiano P, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart. 2011 Oct. 97(20):1675-80. [QxMD MEDLINE Link].
Tribouilloy C, Grigioni F, Avierinos JF, et al. Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets a long-term follow-up multicenter study. J Am Coll Cardiol. 2009 Nov 17. 54(21):1961-8. [QxMD MEDLINE Link].
Magne J, Lancellotti P, O'Connor K, et al. Prediction of exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. J Am Soc Echocardiogr. 2011 Sep. 24(9):1004-12. [QxMD MEDLINE Link].
Bach DS. 2017 ACC expert consensus decision pathway for mitral regurgitation. American College of Cardiology. October 18, 2017. Available at https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/10/18/09/33/2017-acc-expert-consensus-decision-on-mr. Accessed: June 27, 2018.
[Guideline] O'Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017 Nov 7. 70(19):2421-49. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Nishimura RA, Otto CM, Bonow RO, et al, for the ACC/AHA Task Force Members. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10. 129(23):e521-643. [QxMD MEDLINE Link]. [Full Text].
Pizarro R, Bazzino OO, Oberti PF, et al. Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J Am Coll Cardiol. 2009 Sep 15. 54(12):1099-106. [QxMD MEDLINE Link].
Jung JC, Jang MJ, Hwang HY. Meta-analysis comparing mitral valve repair versus replacement for degenerative mitral regurgitation across all ages. Am J Cardiol. 2019 Feb 1. 123(3):446-53. [QxMD MEDLINE Link].
Hata M, Zittermann A, Hakim-Meibodi K, Borgermann J, Gummert J. Minimally invasive mitral valve repair or replacement for degenerative mitral regurgitation. Interact Cardiovasc Thorac Surg. 2019 Apr 1. 28(4):575-80. [QxMD MEDLINE Link].
Otto CM, Bonow RO. Valvular heart disease. In: Libby PP, Bonow RO, MD, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2007. 1625-712.
Thourani VH, Weintraub WS, Guyton RA, et al. Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting. Circulation. 2003 Jul 22. 108(3):298-304. [QxMD MEDLINE Link].
Vahanian A, Iung B. Mitral regurgitation. Timing of surgery or interventional treatment. Herz. 2016 Feb. 41(1):3-9. [QxMD MEDLINE Link].
Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. 2006 May 9. 113(18):2238-44. [QxMD MEDLINE Link].
O’Riordan M. Early surgery bests "watchful waiting" in severe MR patients without symptoms. Medscape Medical News. August 19, 2013. Available at http://www.medscape.com/viewarticle/809403. Accessed: August 25, 2013.
Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA. 2013 Aug 14. 310(6):609-16. [QxMD MEDLINE Link].
Otto CM. Surgery for mitral regurgitation: sooner or later?. JAMA. 2013 Aug 14. 310(6):587-8. [QxMD MEDLINE Link].
[Guideline] Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [QxMD MEDLINE Link]. [Full Text].
O'Riordan M. Repair and surgery fare equally well in ischemic MR. Heartwire from Medscape. November 18, 2013. Available at http://www.medscape.com/viewarticle/814529. Accessed: November 21, 2013.
Barbieri A, Bursi F, Grigioni F, et al. Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: a multicenter long-term international study. Eur Heart J. 2011 Mar. 32(6):751-9. [QxMD MEDLINE Link].
Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation. 2005 Aug 30. 112(9 suppl):I453-7. [QxMD MEDLINE Link].
[Guideline] Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2. 143(5):e35-e71. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: a report of the of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2. 143(5):e72-e227. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Vahanian A, Beyersdorf F, Praz F, et al, for the ESC/EACTS Scientific Document Group; ESC Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021 Aug 28. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11. 70 (2):252-89. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Falk V, Baumgartner H, Bax JJ, et al, for the ESC Scientific Document Group. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017 Oct 1. 52(4):616-64. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Kron IL, LaPar DJ, Acker MA, et al, for the AATS Ischemic Mitral Regurgitation Consensus Guidelines Writing Committee. 2016 update to The American Association for Thoracic Surgery (AATS) consensus guidelines: ischemic mitral valve regurgitation. J Thorac Cardiovasc Surg. 2017 May. 153(5):e97-e114. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015 Nov 21. 36(44):3075-128. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015 Oct 13. 132(15):1435-86. [QxMD MEDLINE Link]. [Full Text].
Kim MJ, Jung HO. Pulmonary hypertension: a long-term risk stratifier in primary mitral regurgitation. Ann Transl Med. 2016 Dec. 4(24):541. [QxMD MEDLINE Link]. [Full Text].
Scarfo I, La Canna G. Is pulmonary artery pressure a trigger of adverse outcome in mitral regurgitation?. Ann Transl Med. 2016 Dec. 4(24):498. [QxMD MEDLINE Link]. [Full Text].
Kaneko H, Neuss M, Weissenborn J, Butter C. Prognostic significance of right ventricular dysfunction in patients with functional mitral regurgitation undergoing MitraClip. Am J Cardiol. 2016 Dec 1. 118(11):1717-22. [QxMD MEDLINE Link].
Fino C, Iacovoni A, Ferrero P, et al. Determinants of functional capacity after mitral valve annuloplasty or replacement for ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2015 Jun. 149(6):1595-603. [QxMD MEDLINE Link].
Feldman T, Cilingiroglu M. Percutaneous leaflet repair and annuloplasty for mitral regurgitation. J Am Coll Cardiol. 2011 Feb 1. 57(5):529-37. [QxMD MEDLINE Link].
Feldman T, Foster E, Glower DG, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011 Apr 14. 364(15):1395-406. [QxMD MEDLINE Link].
Castleberry AW, Williams JB, Daneshmand MA, et al. Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience. Circulation. 2014 Jun 17. 129(24):2547-56. [QxMD MEDLINE Link]. [Full Text].
Zhaohua Y, Wei F, Fei X, Jiqiang Z, Junzhe D, Yangwu S. Concomitant CABG, left ventricular restoration and mitral valve repair for ischemic heart disease. Heart Surg Forum. 2016 Dec 6. 19(6):E272-E275. [QxMD MEDLINE Link].
Feldman T, Kar S, Elmariah S, et al, for the EVEREST II Investigators. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-Year results of EVEREST II. J Am Coll Cardiol. 2015 Dec 29. 66(25):2844-54. [QxMD MEDLINE Link].
Hachinohe D, Latib A, Agricola E, Colombo A. Repeat MitraClip for early recurrent mitral regurgitation. Catheter Cardiovasc Interv. 2018 Sep 1. 92(3):611-6. [QxMD MEDLINE Link].
Acker MA, Parides MK, Perrault LP, et al for The Cardiothoracic Surgical Trials Network. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014 Jan 2. 370(1):23-32. [QxMD MEDLINE Link]. [Full Text].
Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol. 2005 Apr 19. 45(8):1334-40. [QxMD MEDLINE Link].
Carabello BA. Progress in mitral and aortic regurgitation. Prog Cardiovasc Dis. 2001 May-Jun. 43(6):457-75. [QxMD MEDLINE Link].
Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005 Mar 3. 352(9):875-83. [QxMD MEDLINE Link].
Fann JI, Ingels NB, Miller DC. Pathophysiology of mitral valve disease. In: Cohn LH, Edmunds LH (eds). Cardiac Surgery in the Adult. 4th ed. New York: McGraw-Hill; 2012. 795-827.
Khanna D, Miller AP, Nanda NC, et al. Transthoracic and transesophageal echocardiographic assessment of mitral regurgitation severity: usefulness of qualitative and semiquantitative techniques. Echocardiography. 2005 Oct. 22(9):748-69. [QxMD MEDLINE Link].
Mehta RH, Eagle KA, Coombs LP, et al. Influence of age on outcomes in patients undergoing mitral valve replacement. Ann Thorac Surg. 2002 Nov. 74(5):1459-67. [QxMD MEDLINE Link].

Media Gallery

Transthoracic echocardiogram demonstrating severe mitral regurgitation with heavily calcified mitral valve and prolapse of the posterior leaflet into the left atrium.
Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.

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Table 1. Stages of Progression of Chronic Mitral Regurgitation

Table 1. Stages of Progression of Chronic Mitral Regurgitation

Stage	Valve Anatomy	Valve Hemodynamics*	Hemodynamic Consequences	Symptoms
A: Primary MR	Mild MV prolapse with normal coaptation Mild valve thickening and leaflet restriction	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	None	None
A: Secondary MR	Normal valve leaflets, chords and annulus in patient with CAD or cardiomyopathy	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	Normal or mildly dilated LV with infarction or ischemia regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
B: Primary MR	Severe MV prolapse with normal coaptation Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE	Central jet MR area 20-40% LA or late systolic eccentric jet MR Vena contracts < 0.7 cm Regurgitant volume < 60 mL Regurgitant fraction < 50% ERO < 0.40 cm ² Angiographic grade 1-2+	Mild LA enlargement No LV enlargement Normal Pulmonary pressure	None
B: Secondary MR	Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets	Regurgitant volume < 30 mL Regurgitant fraction < 50% ERO < 0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
C: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm ² Angiographic grade 3-4+	Moderate to severe LA enlargement LV enlargement Pulmonary hypertension may be present Stage C1: LVEF >60% and LVESD < 40 mm Stage C2: LVEF ≤60% and LVESD ≥40 mm	None
C: Secondary MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
D: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm ² Angiographic grade 3-4+	Moderate or severe LA enlargement LV enlargement Pulmonary hypertension present	Decreased exercise tolerance Exertional dyspnea
D: Secondary MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	HF symptoms due to MR persist after revascularization and medical therapy Decreased exercise tolerance Exertional dyspnea
*Several criteria are provided but not all criteria for each category will be present. Severity of mild, moderate, or serve is dependent on data quality and integration with other clinical evidence. ^†In secondary MR, true ERO is underestimated due to the crescentic shape of the proximal convergence
CAD = coronary heart disease; ERO = effective regurgitation orifice; HF = heart failure; IE = infective endocarditis; LA = left atrium; LV = left ventricular; LVEF = left ventricular ejection factor; LVESD = left ventricular end-systolic dimension; MR = mitral regurgitation; MV = mitral valve; TTE = transthoracic echocardiography.

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Author

Ivan Hanson, MD Assistant Professor of Medicine, Oakland University William Beaumont School of Medicine

Ivan Hanson, MD is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Luis C Afonso, MD Assistant Professor, Department of Internal Medicine-Cardiology, Program Director of Cardiology Fellowship Program, Wayne State University; Director of Echocardiography Laboratory, Harper University Hospital

Luis C Afonso, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, American Society of Echocardiography

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, American Thoracic Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Actelion, Bayer, Gilead, United Therapeutics<br/>Received research grant from: Actelion, Arena, Gilead, GSK, Liquidia, Reata, United Therapeutics<br/>Received income in an amount equal to or greater than $250 from: Actelion, Complexa, Gilead, Medtronic, Reata, United Therapeutics.

Chief Editor

Terrence X O'Brien, MD, MS, FACC Professor of Medicine/Cardiology, Director, Clinical Cardiovascular Research, Medical University of South Carolina College of Medicine; Director, Echocardiography Laboratory, Veterans Affairs Medical Center of Charleston

Terrence X O'Brien, MD, MS, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Shivkumar H Jha, MD; Jatin Dave, MD, MPH; Kishorkumar Desai, MD; and Abraham G Kocheril, MD, FACC, FACP to the development and writing of this article.

Mitral Regurgitation Guidelines