Indications for Surgical Intervention Mitral Regurgitation and Aortic

Indications for Surgical Intervention —Mitral Regurgitation and Aortic Insufficiency Ryan Hampton OMS IV January 2015

Mitral Regurgitation—Indications for Valve Replacement �Considerations • • • Is MR severe? Is patient symptomatic? Is patient a good candidate? What is Left Ventricular function? Will mitral valve repair improve quality of life and mortality?

Mitral Regurgitation—Indications for Valve Replacement �Severe Chronic Primary MR AND • Symptomatic with LVEF>60% • LVEF between 30 -60% irrespective of symptoms • LVEF <30% only in the event of a primary mitral apparatus defect �Not strong evidence for surgery in LVEF<30% in the event that MR is secondary to LV dysfunction • No significant symptomatic or mortality benefit

Mitral Regurgitation—Indications for Valve Replacement (ref: 2006 ACC/AHA and 2012 Euro Soc Cardiology) � Severe Chronic Primary MR Characteristics (in order of significance) • • • Defined by doppler echocardiography Vena contracta width >/= 7 mm Regurgitant orifice >0. 40 cm 2 Regurgitant volume >/= 60 Regurgitant fraction >/= 50% Jet area > 40% of left atrial area � Almost always need left atrial or left ventricular enlargement for dx of severe MR (LVEDd >60 mm)

Mitral Regurgitation—The Asymptomatic Patient �In the absence of symptoms, management decisions are based on echo and LV function �If Severe chronic MR is identified in presence of Normal LV function (EF>60%), patients should be evaluated every 6 -12 months with repeat echo with decision for surgery deferred until symptoms present or LV function is compromised

Mitral Regurgitation—LV Dysfunciton �If patient has severely impaired left ventricular function (LVEF<30%), MV repair often does not alter long-term mortality or need for pacemaker �ACC/AHA Guidelines • Surgery if: severe MR in presence of LV dysfunction is due to primary mitral apparatus abnormality (not functional MR) causing LV impairment

Mitral Regurgitation—Indications for Valve Replacement (ref: 2006 ACC/AHA and 2012 Euro Soc Cardiology) �Severe Chronic Primary MR—Factors determining timing of surgery • • • Severity Symptoms LV function Valve repair feasibility Presence of AF, Pulmonary HTN Patient preference/expectation

Aortic Regurgitation—Indications for Valve Replacement—Class I Evidence � Severe Chronic AR AND: • Symptomatic • Asymptomatic with LVEF<50% at rest • Asymptomatic, LVEF>50% at rest with LVESd>55 mm or LVEDd>75 mm (and sometimes considered with lower thresholds) • s/p CABG or other valvular or aorta surgery � NOT recommended in asymptomatic patient with LVEF>50% without severe LV dilatation • Periodic echocardiographic monitoring is reasonable

Aortic Regurgitation—Indications for Valve Replacement Waiting for patient to develop exercise intolerance/dysnea may result in some irreversible LV dysfunction � There, valve replacement for AR in asymptomatic patient with chronic severe AR with LVEF<50% is recommended �