1. Ryan Hampton OMS IV January 2015

2.  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?

3.  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

4.  Severe Chronic Primary MR Characteristics (in order of significance) Defined by doppler echocardiography Vena contracta width >/= 7mm Regurgitant orifice >0.40 cm2 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)

5.  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

6.  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

7.  Severe Chronic Primary MR—Factors determining timing of surgery Severity Symptoms LV function Valve repair feasibility Presence of AF, Pulmonary HTN Patient preference/expectation

8.  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

9.  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