Key result
Defining severe SMR solely by 0.2 cm2 EROA risks clinical problems due to LV volume dependence.
Why the study?
Recent guideline revisions defining severe secondary MR at lower cutoffs of EROA (0.2 cm(2)) and regurgitant volume (30 ml) generated controversy regarding diagnostic thresholds.
The definition of severe secondary mitral regurgitation requires careful integration of all echocardiographic and clinical data, as EROA and RVol thresholds depend on LV volume.
Challenges isolated EROA/RVol thresholds for severe secondary MR; leaves open volumetric integration in future definitions.
Secondary mitral regurgitation (MR) is associated with poor outcomes, but its correction does not reverse the underlying left ventricular (LV) pathology or improve the prognosis. The recently published American Heart Association/American College of Cardiology guidelines on valvular heart disease generated considerable controversy by revising the definition of severe secondary MR from an effective regurgitant orifice area (EROA) of 0.4 to 0.2 cm(2), and from a regurgitant volume (RVol) of 60 to 30 ml. This paper reviews hydrodynamic determinants of MR severity, showing that EROA and RVol values associated with severe MR depend on LV volume. This explains disparities in the evidence associating a lower EROA threshold with suboptimal survival. Redefining MR severity purely on EROA or RVol may cause significant clinical problems. As the guidelines emphasize, defining severe MR requires careful integration of all echocardiographic and clinical data, as measurement of EROA is imprecise and poorly reproducible.
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Grayburn et al. (2014) conducted a review in Secondary mitral regurgitation. Redefining severe secondary mitral regurgitation purely on an effective regurgitant orifice area of 0.2 cm2 or regurgitant volume of 30 ml may cause clinical problems as these depend on LV volume.
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