Mitral Regurge guidelines

Question 1

Mild MR

Answer 1

— Jet area <20%

— vena contracta <0.3 cm

— Regurgitant volume < 30 ml

— Regurgitant Fraction < 30

— Effective regurg orifice area < 0.2 cm2

Question 2

Moderate MR

Answer 2

— Jet area <20-40 %

— vena contracta <0.3-0.7 cm

— Regurgitant volume < 30-60 ml

— Regurgitant Fraction < 30-50%

— Effective regurg orifice area < 0.2-0.4 cm2

Question 3

Severe MR

Answer 3

— Jet area >40 %

— vena contracta >0.7 cm

— Regurgitant volume >60 ml

— Regurgitant Fraction >50%

— Effective regurg orifice area >0.4 cm2

— angiographic grading 3-4+

Question 4

Stage A of primary MR

Answer 4

— At risk

— mild mitral collapse with normal coapt

— mild thickenicng and leaflet restrction

Question 5

Stage B of primary MR

Answer 5

— progressive mod MR

— severe mitral prolapse + normal coap

— Rheumatic chnages + loss of coapt

— prior IE

— mild LA enlar

— no LV enlargement

— normal pulmonary pressure

Question 6

Stage C of primary MR

Answer 6

Sev mitral prolapse + loss of capt or flail leaflet

Rheu changes, prior IE, thicken of leaflet with radiation

mod-sev LA enl, LV enl, P.Htn with exercise or rest

C1: LVEF > 60%, LVESD < 40 mm

C2: LVEF < 60%, LVESD > 40 mm

Question 7

Stage D of primary MR

Answer 7

Sev mitral prolapse + loss of capt or flail leaflet

Rheu changes, prior IE, thicken of leaflet with radiation

mod-sev LA enl, LV enl, P.Htn present

Decreased exercise tolerance

exertional dyspnea

Question 8

Class I (CPMR)

Answer 8

– MV surg for Sx + ch sev MR (D) + EF >30%

– MV surg for Asx + ch sev MR + EF <60, LVESD >40

(C2)

– MVr > MVR if ind for ch sev MR limited to post leafl.

– MVr > MVR if MR inv ant leaf or both when successful durable repair can be done

– MV surg for Ch sev (C,D) undergoing cardiac surg

Question 9

Class IIa (CPMR)

Answer 9

– MVr for sev, asx (C1) if successful durable repair without residual MR is >95% with mort < 1% in ex cent

– MVr for sev, asx (C1) if successful durable repair in patients with new onset AF or resting pulm HTN >50

– MVr for chronic mod MR if undergoing other C. surg

(B)

Question 10

Class IIb (CPMR)

Answer 10

– Sev, Sx (D) + LVEF<30%

– MVr in Rh mitral disease if surgery is ind. and durable, successful repair is likely

– transcath MVr for Sev, Sev Sx (III,IV) + reasonable life expect., + sev comorbidities (prohibitive S. risk)

Question 11

Class III (CPMR)

Answer 11

— MV replacement should not be done for isolated severe Primary MR limited to less than one half of the posterior leaflet unless MV repair has been attempted and was unsuccessful

Question 12

Stage A of Secondary MR

Answer 12

— At risk

— normal leaflets, chords, annulus + CAD, cardiomyo.

— normal or lid dil LV + fixed inf or inducible WM abn

— primary myocardial disease

— Sx due to CAD or HF may be present and respond to revasc or app med ttt

Question 13

Stage B of secondary MR

Answer 13

— Progrssive MR (mod)

— Reg WM abn + mild leaflet tethering

— annular dil + mild loss of central coap

— Reg WM abn + reduced EF, LV dil and dysf due to prim myocardial disease

— Sx due to CAD or HF may be present and respond to revasc or app med ttt

Question 14

Stage C of secondary MR

Answer 14

— Sev, Asx MR

— Reg WM abn + severe leaflet tethering

— annular dil + severe loss of central coap

— Reg WM abn + reduced EF, LV dil and dysf due to prim myocardial disease

— Sx due to CAD or HF may be present and respond to revasc or app med ttt

Question 15

Stage D of secondary MR

Answer 15

— Sev, Sx MR

— Reg WM abn + mild leaflet tethering

— annular dil + mild loss of central coap

— Reg WM abn + reduced EF, LV dil and dysf due to prim myocardial disease

— HF sx due to MR persist even after revasc. and op med ttt, Decreased exercise tol, exertional dyspnea

Question 16

Class IIa (CSMR)

Answer 16

— MV surgery reas. (C,D) if underg. CABG or AVR

Question 17

Class IIb (CSMR)

Answer 17

— MV sur, considered for sev, sev Sx (III, IV) MR

— MVr considered for mod (B) underg other C surg.