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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 e127 CLINICAL STATEMENTS AND GUIDELINES

calculated ERO; the severity of secondary MR may increase over time because of adverse remodeling of the LV or mitral annulus; and Doppler methods for calculations of ERO area by the flow convergence method may underestimate severity because of the crescentic shape of the regurgitant orifice.1,2 Even so, on the basis of the criteria used for determination of “severe” MR in RCTs of surgical intervention for secondary MR,3–6 the recommended definition of severe secondary MR is now the same as for primary MR (ERO ≥0.4 cm2 and regurgitant volume ≥60 mL) (Table 18).

7.3.2 Diagnosis of Chronic Secondary MR

Recommendations for Diagnosis of Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 31.

COR LOE Recommendations

1 B-NR 1.  In patients with chronic secondary MR (Stages B to D), TTE is useful to establish the etiology and to assess the extent of regional and global LV remodeling and systolic dysfunction, severity of MR, and magnitude of pulmonary hypertension.1,2

1 C-EO 2.  In patients with chronic secondary MR (Stages B to D), noninvasive imaging (stress nuclear/ PET, CMR, or stress echocardiography), coronary CT angiography, or coronary arteriography is useful to establish etiology of MR and to assess myocardial viability.

1 B-NR 3.  In patients with chronic secondary MR with severe symptoms (Stage D) that are unresponsive to GDMT who are being considered for transcatheter mitral valve interventions, TEE is indicated to determine suitability for the procedure.3–8

1 C-EO 4.  In patients with chronic secondary MR undergoing transcatheter mitral valve intervention, intraprocedural guidance with TEE is recommended.4,7,9–13

Synopsis

In symptomatic patients with chronic secondary MR, TTE is the initial diagnostic modality. Assessment of the coronary anatomy and myocardial viability may be helpful in management if ischemic MR is suspected. If transcatheter mitral valve intervention is contemplated, TEE determines suitability for the procedure and guides the procedure.1

Recommendation-Specific Supportive Text

1.	 TTE is essential in patients with MR to identify patients with primary MR and those with secondary forms of MR. In general, in patients with LV systolic dysfunction and symptoms of HF, the presence of chronic secondary MR of any severity is associated with a worse prognosis than that seen in the absence of MR. Most patients with secondary MR have global LV dysfunction, but in some patients, a limited but strategically placed wall motion abnormality may also cause chronic secondary MR. An initial TTE helps establish the cause of chronic secondary MR and also serves as a baseline for future comparisons. In patients with secondary MR, severe MR is defined as an ERO ≥40 mm2, but outcome studies have shown poor prognosis in those with moderate MR (ERO ≥20 mm2).1,2

2.	 Prognosis is poor for both ischemic and nonischemic MR, but ischemic MR lends itself to the possibility of revascularization and potential improvement in LV function if CAD has led to large areas of hibernating viable myocardium. Long-term results of the STICH (Surgical Treatment for Ischemic Heart Failure) trial demonstrated an improved 10-year survival rate in patients with ischemic cardiomyopathy and LVEF <35% who underwent CABG plus GDMT as compared with those randomized to GDMT alone. CT angiography is usually adequate to rule out significant CAD and thus rule out ischemic MR. If CAD is detected and noninvasive testing demonstrates areas of viability, coronary arteriography is pursued to better define the anatomy for potential revascularization.14,15 Although the presence of myocardial viability did not determine the effect of revascularization on survival in the STICH trial, there is a subset of patients with viable myocardium in whom the ischemic MR will respond to revascularization.16–18 3.	 Clinical trials have identified anatomic considerations, detectable by TEE, that can identify patients with secondary MR who have a valve morphology amenable to TEER. In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial of patients with secondary MR and HF, exclusion criteria included vertical coaptation length <2 mm in valves with leaflet tethering, evidence of calcification in the grasping area of the A2 or P2 scallops, presence of a significant cleft of A2 or P2 scallops, and lack of both primary and secondary chordal support. These are similar criteria to the earlier EVEREST trial. TEE is standard preprocedural imaging to determine suitability for TEER.3–8 4.	 During mitral TEER, TEE assists in guiding positioning of the clip(s), assessing success of the procedure, determining whether more than a single clip is necessary to reduce MR, and assuring that the clip(s) has not created MS.4,7,9–13

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