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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e121 CLINICAL STATEMENTS AND GUIDELINES

4.	 Intraoperative TEE is the standard for imaging during MR surgery. Before the operative incision, TEE may give the surgeon a better understanding of the valve anatomy and type of repair that will likely be performed, although this decision is ultimately made when the valve is inspected visually.10,11 Three-dimensional TEE (“surgical view”) may be helpful in further visualizing the abnormal mitral valve anatomy. Because anesthesia lessens afterload, preload, and mitral valve closing force, decisions about severity of MR should be evaluated at the same loading conditions as occurred during the awake state. Intraoperative TEE is especially helpful in gauging the adequacy of repair.11 Because even mild residual MR after repair increases the likelihood of later repair failure that would necessitate reoperation,21 surgeons strive for near-perfect operative repair. Adequacy of repair is judged by TEE after physiological filling pressure and blood pressure have been established. If more than trivial MR is detected in the operating room after repair, repair revision usually ensues. TEE also helps to diagnose underfilling of the LV, which can lead to systolic anterior leaflet motion with outflow obstruction and unneeded repair. In those patients with primary severe MR who are at high surgical risk, TEE is helpful in determining the feasibility of transcatheter edge-to-edge repair.22,23

7.2.2.2 Diagnostic Testing: Changing Signs or Symptoms

Recommendation for Diagnostic Testing: Changing Signs or Symptoms in Patients With Primary MR Referenced studies that support the recommendation are summarized in Online Data Supplement 26. COR LOE Recommendation

1 B-NR 1.  In patients with primary MR (Stages B to D) and new-onset or changing symptoms, TTE is indicated to evaluate the mitral valve apparatus and LV function.1,2

Synopsis

A repeat TTE provides clinically relevant information about patients who are being followed for primary MR who develop new-onset symptoms.

Table 17.  Stages of Chronic Primary MR

Stage Definition Valve Anatomy Valve Hemodynamics* Hemodynamic Consequences Symptoms A At risk of MR Mild mitral valve prolapse with normal coaptation

Mild valve thickening and leaflet restriction No MR jet or small central jet area <20% LA on Doppler

Small vena contracta <0.3 cm None None

B Progressive MR Moderate to severe mitral valve prolapse with normal coaptation

Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Central jet MR 20%–40% LA or late systolic eccentric jet MR

Vena contracta <0.7 cm Regurgitant volume <60 mL Regurgitant fraction <50% ERO <0.40 cm2 Angiographic grade 1+ to 2+ Mild LA enlargement

No LV enlargement Normal pulmonary pressure None

C Asymptomatic severe MR Severe mitral valve prolapse with loss of coaptation or flail leaflet

Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease 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 cm2 Angiographic grade 3+ to 4+ Moderate or severe LA enlargement

LV enlargement Pulmonary hypertension may be present at rest or with exercise C1: LVEF >60% and LVESD <40 mm C2: LVEF ≤60% and/or LVESD ≥40 mm None

D Symptomatic severe MR Severe mitral valve prolapse with loss of coaptation or flail leaflet

Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease 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 cm2 Angiographic grade 3+ to 4+ Moderate or severe LA enlargement

LV enlargement Pulmonary hypertension present Decreased exercise tolerance

Exertional dyspnea

*Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence. ERO indicates effective regurgitant orifice; IE, infective endocarditis; LA, left atrium/atrial; LV, left ventricular; LVEF, left ventricular ejection fraction; LVESD; left ventricular end-systolic dimension; and MR, mitral regurgitation.

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