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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 e129 CLINICAL STATEMENTS AND GUIDELINES

7.3.4 Intervention

Recommendations for Intervention for Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 31. COR LOE Recommendations

2a B-R 1.  In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent symptoms (NYHA class II, III, or IV) while on optimal GDMT for HF (Stage D), TEER is reasonable in patients with appropriate anatomy as defined on TEE and with LVEF between 20% and 50%, LVESD ≤70 mm, and pulmonary artery systolic pressure ≤70 mm Hg.1–8

2a B-NR 2.  In patients with severe secondary MR (Stages C and D), mitral valve surgery is reasonable when CABG is undertaken for the treatment of myocardial ischemia.9–15

2b B-NR 3.  In patients with chronic severe secondary MR from atrial annular dilation with preserved LV systolic function (LVEF ≥50%) who have severe persistent symptoms (NYHA class III or IV) despite therapy for HF and therapy for associated AF or other comorbidities (Stage D), mitral valve surgery may be considered.16–20

2b B-NR 4.  In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent severe symptoms (NYHA class III or IV) while on optimal GDMT for HF (Stage D), mitral valve surgery may be considered.9,12,21–43

2b B-R 5.  In patients with CAD and chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) (Stage D) who are undergoing mitral valve surgery because of severe symptoms (NYHA class III or IV) that persist despite GDMT for HF, chordal-sparing mitral valve replacement may be reasonable to choose over downsized annuloplasty repair.9,12,21–32,44–47

Synopsis

Mitral TEER is indicated to improve symptoms and prolong life in a select subset of patients with chronic severe secondary MR, LV systolic dysfunction, and persistent severe symptoms while on optimal GDMT. Surgery may improve symptoms in these patients, with mitral valve replacement preferred over repair. A subset of patients with severe MR attributable to AF may benefit from mitral valve surgery and concomitant atrial maze procedure (Figure 9).

Recommendation-Specific Supportive Text

1.	 The COAPT trial of transcatheter treatment of secondary MR demonstrated improvement in survival, hospitalization, symptoms, and quality of life in patients with persistent symptoms despite optimization of GDMT who were randomized to TEER, as compared with those randomized to continued GDMT. In contrast, MITRA-FR (Multicentre Randomized Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation) enrolled patients with greater degrees of LV enlargement and less severe MR (mean ERO area 0.31 cm2 versus 0.41 cm2) and reported no benefit of TEER in reducing the composite endpoint of death or hospitalization as compared with medical therapy. In addition, the inclusion criterion in MITRA-FR of an LVESD up to 70 mm represents extreme dilation; in contrast, in the COAPT trial, the mean LVESD was smaller (52±9 mm), and even the LVEDD rarely exceeded 70 mm (mean 62±7 mm). Thus, the enrollment criteria in COAPT trial (LVEF between 20% and 50%, LVESD ≤70 mm, pulmonary artery systolic pressure ≤70 mm Hg, and persistent symptoms [NYHA class II, III, or IV] while on optimal GDMT) are the current standard selection criteria for TEER for secondary MR. Observational studies have suggested that a greater reduction in MR severity with TEER is associated with greater  LV and LA reverse remodeling.1–8,48,49 The exact anatomy and mechanism of MR also needs to be taken into consideration when determining candidacy for transcatheter repair. 2.	 There is no proof that surgical correction of chronic secondary MR is effective in prolonging life, but observational studies and a substudy of the randomized STICH trial suggest that it is wise to address the mitral valve during CABG for severe CAD when secondary MR is severe. Although it may be hoped that the revascularization will recruit hibernating myocardium and reduce chronic secondary MR, this has not been demonstrated, and failing to correct chronic severe secondary MR may leave the patient with severe residual MR. The risks and benefits of additional surgical interventions should be weighed in patients with LV systolic dysfunction.9–13 For patients with secondary MR undergoing operation for other valve disease, see Section 10.2 (Timing of Intervention for Mixed Valve Disease). 3.	 MR may develop in patients with preserved LV systolic function who have progressive LA dilation, leading to enlargement of the mitral annulus and malcoaptation of the leaflets.51,52 This may arise in conditions such as HF with preserved LVEF, restrictive cardiomyopathy, and nonobstructive hypertrophic cardiomyopathy. These patients often have associated AF, which may contribute to the progression of LA and annular dilation, thus increasing the severity of MR,18,53 and successful ablation of AF may reduce or eliminate MR.53 Isolated annular dilation accounts for <20% of patients referred for surgery of severe MR in the STS database, but it is also the etiology with

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