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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 e125 CLINICAL STATEMENTS AND GUIDELINES

still worse prognosis. Because the loading conditions in MR allow continued late ejection into a lower-impedance LA, a higher cutoff for “normal” LVEF is used in MR than in other types of heart disease. Although it is clearly inadvisable to allow patients’ LV function to deteriorate beyond the benchmarks of an LVEF ≤60% or LVESD ≥40 mm, some recovery of LV function can still occur even if these thresholds have been crossed.5,32 3.	 Repair success increases with surgical volume and expertise, which is a principle guiding surgical referral.21,27 However, mitral valve replacement is preferable to a poor repair. The results of a minimally invasive approach may be similar to those of a full median sternotomy if the minimally invasive operation is performed by highly experienced surgeons.33–38 When leaflet dysfunction is limited so that only annuloplasty and repair of the posterior leaflet are necessary, an operative mortality rate of <1%, long-term survival rate equivalent to that of the age-matched general population, approximately 95% freedom from reoperation, and >80% freedom from recurrent moderate or severe MR at 15 to 20 years after operation are exp ected.23,24,39,40

4.	 The onset of symptoms, LV dysfunction, or pulmonary hypertension worsens the prognosis for MR. Careful surveillance may result in timing of valve surgery before these negative sequelae occur. However, an attractive alternative strategy for treating severe chronic primary MR is to perform early mitral repair before these triggers are reached. Early mitral repair avoids the need for intensive surveillance and also obviates the possibility that patients might become lost to follow-up or delay seeing their clinician until advanced LV dysfunction has already ensued.4,13,16,22 For the early mitral repair strategy to be effective, a durable repair must be provided. An unwanted valve replacement and its attendant risks, or a failed repair necessitating reoperation, could be a complication of this

Figure 8. Primary MR. Colors correspond to Table 2. *See Prosthetic Valve section (11.1.2) for choice of mitral valve replacement if mitral valve repair is not possible. CVC indicates Comprehensive Valve Center; ERO, effective regurgitant orifice; ESD, end-systolic dimension; LVEF, ejection fraction; MR, mitral regurgitation; MV, mitral valve; MVR, mitral valve replacement; RF, regurgitant fraction; RVol, regurgitant volume; and VC, vena contracta.

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