p.53 抽出テキスト

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 e124

CLINICAL STATEMENTS AND GUIDELINES mitral valve prolapse, worsening rather than decreasing severity of MR.6 The foregoing does not apply to patients with concomitant hypertension. Hypertension must be treated because of the wellknown morbidity and mortality associated with that condition and because increased LV systolic pressure by itself increases the systolic transmitral gradient and worsens severity of MR.

7.2.4 Intervention

Recommendations for Intervention for Chronic Primary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 30. COR LOE Recommendations

1 B-NR 1.  In symptomatic patients with severe primary MR (Stage D), mitral valve intervention is recommended irrespective of LV systolic function.1,2

1 B-NR 2.  In asymptomatic patients with severe primary MR and LV systolic dysfunction (LVEF ≤60%, LVESD ≥40 mm) (Stage C2), mitral valve surgery is recommended.3–10

1 B-NR 3.  In patients with severe primary MR for whom surgery is indicated, mitral valve repair is recommended in preference to mitral valve replacement when the anatomic cause of MR is degenerative disease, if a successful and durable repair is possible.11–15

2a B-NR 4.  In asymptomatic patients with severe primary MR and normal LV systolic function (LVEF ≥60% and LVESD ≤40 mm) (Stage C1), mitral valve repair is reasonable when the likelihood of a successful and durable repair without residual MR is >95% with an expected mortality rate of <1%, when it can be performed at a Primary or Comprehensive Valve Center.4,13,16

2b C-LD 5.  In asymptomatic patients with severe primary MR and normal LV systolic function (LVEF >60% and LVESD <40 mm) (Stage C1) but with a progressive increase in LV size or decrease in EF on ≥3 serial imaging studies, mitral valve surgery may be considered irrespective of the probability of a successful and durable repair.16

2a B-NR 6.  In severely symptomatic patients (NYHA class III or IV) with primary severe MR and high or prohibitive surgical risk, transcatheter edge-toedge repair (TEER) is reasonable if mitral valve anatomy is favorable for the repair procedure and patient life expectancy is at least 1 year.17,18

2b B-NR 7.  In symptomatic patients with severe primary MR attributable to rheumatic valve disease, mitral valve repair may be considered at a Comprehensive Valve Center by an experienced team when surgical treatment is indicated, if a durable and successful repair is likely.19

3: Harm B-NR 8.  In patients with severe primary MR where leaflet pathology is limited to less than one half the posterior leaflet, mitral valve replacement should not be performed unless mitral valve repair has been attempted at a Primary or Comprehensive Valve Center and was unsuccessful.11–14,20–22 Synopsis

Anterior and/or bileaflet primary mitral valve disease requires a complex and extensive repair,20,23–26 and durability of the repair is less certain than for simple posterior leaflet intervention. Freedom from reoperation is approximately 80%, and freedom from recurrent moderate or severe MR is 60% at 15 to 20 years in complex cases. These results are superior to the results of mitral valve replacement if the repair is performed at high-volume valve surgery centers,27–29 even in elderly patients.30,31 Repair should also be attempted, if possible, with other causes of severe MR, such as papillary muscle rupture, IE, and cleft mitral valve. However, the results of very complex repair in younger patients may be matched by the results of durable mechanical mitral valve replacement with careful management of anticoagulation. The Heart Valve Team should assign complex repairs to experienced mitral valve surgeons with established excellent operative and long-term outcomes. The probability of mitral valve repair rather than mitral valve replacement and overall outcome correlate with surgeon-specific mitral volumes.21,27 The hospital mortality rate is 50% lower, on average, in the highest-volume hospitals that perform 50 repairs per year. However, some low-volume hospitals outperform the median high-volume hospitals. This overlap suggests that hospital- or surgeon-specific volumes should not be used as a surrogate for actual surgeon-specific repair rates and outcomes (Figure 8). The management of patients with combined severe primary MR and AS is discussed in the Mixed Valve Disease section (Section 10.2.2).

Recommendation-Specific Supportive Text

1.	 Primary MR is a mechanical problem of the leaflet coaptation that has only a mechanical solution— that of mitral valve mechanical intervention. The onset of symptoms that results from severe MR worsens prognosis even when LV function appears to be normal,1,2 and the negative prognosis extends even to mild symptoms.2 Thus, the onset of symptoms is an indication for prompt mitral valve surgery. 2.	 The goal of therapy in MR is to correct it before the onset of LV systolic dysfunction and its subsequent adverse effect on patient outcomes. The ideal time for mitral valve surgery is when the patient’s LV approaches but has not yet reached the parameters that indicate systolic dysfunction (LVEF ≤60% or LVESD ≥40 mm).3–7,16 Because symptoms do not always coincide with LV dysfunction, imaging surveillance is used to plan surgery before severe dysfunction has occurred. If moderate LV dysfunction is already present, prognosis is worse after mitral valve operation.5–7,9,10,16 Thus, further delay (although symptoms are absent) will lead to greater LV dysfunction and a

Downloaded from http://ahajournals.org by on October 7, 2026