MR ACC/AHA guidelines for management

Associate Editor-In-Chief:

Class I
1. MV surgery is recommended for the following patients: A. Symptomatic patients with acute severe MR. (Level of Evidence: B) B. Patients with chronic severe MR and NYHA functional class II, III, or IV symptoms in the absence of severe LV dysfunction (severe LV dysfunction is defined as EF less than 0.30 and/ or end-systolic dimension greater than 55 mm). (Level of Evidence: B) C. Asymptomatic patients with chronic severe MR and mild to moderate LV dysfunction, EF 0.30 to 0.60, and/or end-systolic dimension greater than or equal to 40 mm. (Level of Evidence: B)

2. MV repair is recommended over MV replacement (MVR) in the majority of patients with severe chronic MR who require surgery, and patients should be referred to surgical centers experienced in MV repair. (Level of Evidence: C)

Class IIa
1. MV repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe MR with preserved LV function (EF greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual MR is greater than 90%. (Level of Evidence: B) 2. MV surgery is reasonable for the following patients:

A. Asymptomatic patients with chronic severe MR, preserved LV function, and (1) new onset of atrial fibrillation or (2) pulmonary hypertension (pulmonary artery systolic pressure greater than 50 mm Hg at rest or greater than 60 mm Hg with exercise). (Level of Evidence: C)

B. Patients with chronic severe MR due to a primary abnormality of the mitral apparatus, NYHA functional class III-IV symptoms, and severe LV dysfunction (EF less than 0.30 and/ or end-systolic dimension greater than 55 mm) in whom MV repair is highly likely. (Level of Evidence: C)

Class IIb
1. MV repair may be considered for patients with chronic severe secondary MR due to severe LV dysfunction (EF less than 0.30) who have persistent NYHA functional class III-IV symptoms despite optimal therapy for heart failure, including biventricular pacing. (Level of Evidence: C)

Class III
1. MV surgery is not indicated for asymptomatic patients with MR and preserved LV function (EF greater than 0.60 and end-systolic dimension less than 40 mm) in whom significant doubt about the feasibility of repair exists. (Level of Evidence: C) 2. Isolated MV surgery is not indicated for patients with mild or moderate MR. (Level of Evidence: C)