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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e122 CLINICAL STATEMENTS AND GUIDELINES Recommendation-Specific Supportive Text 1. The onset of symptoms in severe MR (dyspnea on exertion, orthopnea, or declining exercise tolerance) is an indication for mitral intervention even if LV function is preserved.2 Symptoms are the culmination of the pathophysiology of MR and may indicate changes in LV or LA compliance; increase in pulmonary artery pressure; decrease in RV function; or the coexistence of TR. Therefore, symptoms add pathophysiological data not readily available from imaging, if other confounding factors can be excluded. Furthermore, there is no evidence that treatment with diuretics or other therapies that might relieve symptoms changes the prognostic effect of symptom onset. Once symptoms have occurred and are caused by MR, mitral valve surgery will improve the natural history even if medication has led to improvement. Repeat TTE at the time of symptom onset is indicated to confirm that symptoms are likely attributable to MR or its effect on the LV, which in turn supports surgical correction.1 The new onset of AF is also an indication for repeat TTE to look for changes in severity of MR and the status of the LV. 7.2.2.3 Diagnostic Testing: Routine Follow-Up Recommendations for Diagnostic Testing: Routine Follow-Up for Chronic Primary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 27. COR LOE Recommendations 1 B-NR 1. For asymptomatic patients with severe primary MR (Stages B and C1), TTE is indicated every 6 to 12 months for surveillance of LV function (estimated by LVEF, LVEDD, and LVESD) and assessment of pulmonary artery pressure.1–11 2b B-NR 2. In asymptomatic patients with severe primary MR (Stages B and C1), use of serum biomarkers and novel measurements of LV function, such as global longitudinal strain, may be considered as an adjunct to guide timing of intervention.12–21 Synopsis Asymptomatic patients with severe primary MR require periodic TTE to determine optimal timing of intervention. Biomarkers and other measures of LV function, such as global longitudinal strain, may also be helpful to guide intervention. Recommendation-Specific Supportive Text 1. TTE provides valuable information for surveillance of LV function (estimated by LVEF and LVESD) and pulmonary artery pressure in asymptomatic patients with severe primary MR (Stage C1) if performed every 6 to 12 months.1,2,4,5,7–11 Chronic severe MR is tolerated poorly, reaching a trigger for surgery at an average rate of about 8% per year.5,10 This progression varies from patient to patient, and because prognosis worsens if correction of MR is delayed beyond the onset of these triggers, referral to a Comprehensive Valve Center for early repair or careful surveillance is of value. Because echocardiographic measurements are variable, management decisions that rest on these measurements should be confirmed by repeat sequential TTE. In patients with milder chronic primary MR (Stages A and B), TTE is indicated periodically to evaluate for changes in MR severity, depending on valve anatomy and other considerations, because regurgitation may worsen over time. Because this process may develop slowly, MR can become severe and even lead to LV dysfunction in the absence of symptoms or clinical signs (Table 4).3,6 2. Symptom onset is a crucial demarcation point in the natural history of MR and also a trigger for intervention. Because symptoms develop gradually, patients may fail to recognize or ignore symptoms. Natriuretic peptide levels provide objective evidence in patients with chronic severe MR, with elevated levels indicating increased reliance on preload to maintain an adequate forward cardiac output.12–18,20 Thus, serum natriuretic peptide levels may be helpful in making management decisions about intervention when other data are conflicting. LVEF is used as a key determinant of LV function in timing MR intervention. Unfortunately, LVEF is load dependent and often overestimates LV function in MR. Global longitudinal strain, although also load dependent, appears more sensitive to LV dysfunction in patients with chronic MR and, as such, might give warning that LV function is declining before LVEF becomes abnormal.15,16,19,21 Thus, novel markers of LV systolic function, such as global longitudinal strain, may be useful adjuncts in assessing LV function in patients with chronic MR. 7.2.2.4. Diagnostic Testing: Cardiac Catheterization Left ventriculography and hemodynamic measurements are useful when clinical assessment and noninvasive tests are inconclusive or discordant with regard to 1) severity of MR, 2) LV function, or 3) the need for surgery.1 Noninvasive imaging is adequate for evaluation of MR in most cases. However, invasive hemodynamic evaluation may be necessary in some cases, especially when there is a clinical discrepancy between symptomatic status and noninvasive testing. Elevated filling pressures support a cardiac cause of dyspnea and may indicate severely abnormal pathophysiology even when the patient claims to be asymptomatic. Conversely, a normal invasive hemodynamic examination in a symptomatic Downloaded from http://ahajournals.org by on October 7, 2026