Primary Mitral Regurgitation Degenerative Mitral Valve Disease Pathology Evidence for superiority of repair

Height of the Anterior and Posterior Leaflets of the Mitral Valve, Modified from Lam Posterior Leaflet Posterior Leaflet Posterior Leaflet Anterior Leaflet Cusp Anterolateral Scallop (P1) Middle Scallop (P2) Commissural Scallop (P3) Male (26) Female (24) Female (24 Height (cm) Width (cm) 2.4 (2.0-3.0) 3.6 (2.5-4.8) 2.2 (1.8-3.5) 2.9 (1.8-4.2) 1.1 (0.9-2.0) 1.6 (0.9-4.0) 1.0 (0.8-1.4) 1.4 (0.9-2.0) 1.4 (0.9-2.0) 2.3 (1.3-3.8) 1.2 (0.7-1.8) 1.8 (0.6-2.6) 1.0 (0.6-1.7) 1.5 (0.9-3.1) 0.8 (0.5-1.1) 1.1 (0.5-2.2) Lam JHC, Ranganathan N, Wigle ED, Silver MD. Morphology of the human mitral valve. II. The valve leaflets. Circulation 41:459-67, 1970.

Floppy Mitral Valve/Mitral Valve Prolapse: Prevalence Method Number of Cases FMV/MVP(%) Auscultation 79,698 1.4-6.3 Echocardiogram 11,431 4.5-14.5 Necropsy 6,529 1.0-7.4 FMV = floppy mitral valve; MVP = mitral valve prolapse. Mitral Valve: H. Boudoulas & C. Wooley

Floppy mitral valve. Graphic presentation of the morphological characteristics of normal mitral valve And floppy mitral valve associated with severe mitral valvular regurgitation. Valve diameter (mm), valve Surface area (mm2), and chordal length (cm) are presented. AL = anterior leaflet. Mitral Valve: H. Boudoulas & C. Wooley

Estimated lifetime risk of mitral valve surgery by age and sex among cohorts diagnosed as having MVP. Age specific events were calculated from the State of New South Wales, Australia. M = male; F = female. Mitral Valve: H. Boudoulas & C. Wooley

Floppy mitral valve (FMV), mitral valve prolapse (MVP), and mitral valvular regurgitation (MVR). Symptoms are plotted against patient age in years. Increased symptoms occurred after age 50 and are related to progressive MVR, atrial fibrillation, left atrial (LA), and left ventricular (LV) dysfunction, and congestive heart failure (CHF). Thromboembolic complications, infective endocarditis, and cardiac arrhythmias have been reported at a wide range of ages. Mitral Valve: H. Boudoulas & C. Wooley

Evidence Supporting Repair of Degenerative Mitral Valve Disease with Severe Mitral Regurgitation Slides to follow

Briefly, this work can be summarized: It was shown that mitral valve repair vs replacement had greater survival rate. Replacement techniques and survival were improved by chordal sparing techniques, but repair remained superior. In patients with flail mitral valve leaflet and MR, medically treated patients had decreased survival compared to the normal population. For patients with flail mitral leaflet and MR, 60% would have heart failure 10 years after diagnosis.

Briefly, this work can be summarized: In these patients (flail MV leaflet and MR), LV ejection fraction was shown to affect survival. EF>60% had 10 year survival of 61%: LVEF <60% had 10 year survival of 40%. Patient survival rate was also influenced by severity of mitral regurgitation Patients with flail leaflet and MR had increased incidence of cardiac events (death, CHF, new AFib). Patients with flail leaflet and severe MR who underwent successful repair had improved survival, lack of progression of CHF compare to medically treated patients.

Clinical Course of Medically Treated Flail Mitral Valve Leaflets Overall survival (Kaplan-Meier estimates) among patients with asymptomatic MR under medical management stratified according to the ERO. (Modified from Sarona and coworkers.) Rates (Kaplan-Meier estimates) of cardiac events (cardiac death, congestive heart failure, or new atrial fibrillation) among patients with asymptomatic MR under stratified by ERO. (Modified from Sarono and coworkers.) Semin Thorac Cardiovasc Surg 19:97-102, 2007.

Clinical Course of Medically Treated Flail Mitral Valve Leaflets Long-term survival with medical treatment, as compared with expected survival, in 229 patients with MR due to flail leaflet. (Modified from Ling and coworkers.) Incidence of atrial fibrillation (AF), congestive heart failure (CHF), and mitral valve surgery during follow-up. The numbers are event rates (mean ± standard error of the mean) at 10 years. (Modified from Ling and coworkers.) Semin Thorac Cardiovasc Surg 19:97-102, 2007.

Survival of Patients with Flail Leaflet MR – Surgery vs Medical Therapy Overall survival from time of diagnosis in patients with MR due to flail leaflets according to the management strategy selected at baseline. Survival was significantly better in patients who had early surgery than in those who had conservative management. (Rx) (Modified from Ling and coworkers.) Survival adjusted to age and ejection fraction according to the management strategy selected at baseline for patients in NYHA class I or II (left) and for those in class III or IV (right). Rx indicates management. (Modified from Ling and coworkers.) Semin Thorac Cardiovasc Surg 19:97-102, 2007.

Survival Mitral Valve Repair vs Replacement Overall survival of patients having valve repair or valve replacement for severe MR. Note the statistically significant difference between the groups (P=0.0004) and the similarity of survival of patients who had valve repair compared with the expected survival rate. (Modified from Enriquz-Sarono.) Late survival (>30 days or after discharge from the hospital) after mitral valve re-repair or replacement at Reoperation for recurrent MR. The late survival associated with mitral valve repair is greater than that seen after mitral replacement (mortality hazard ratio for re-repair, 0.49; P=0.05 vs valve replacement). (Modified from Suri and coworkers.) Semin Thorac Cardiovasc Surg 19:97-102, 2007.

Table 15. 2014 AHA/ACC Stages of Primary MR Nishimura, RA et al. 2014 AHA/ACC Valvular Heart Disease Guideline

Table 17. 2014 AHA/ACC Summary of Recommendations for Chronic Primary MR Nishimura, RA et al. 2014 AHA/ACC Valvular Heart Disease Guideline

Figure 4. 2014 AHA/ACC Indications for Surgery for MR Nishimura, RA et al. 2014 AHA/ACC Valvular Heart Disease Guideline