Insight from International Guidelines: do We Have Satisfactory Recommendations for Secondary Mitral Regurgitation?

Figures

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  Fig. 1.. provides an overview of the different steps to follow in the decision-making process which include identification, definition, assessment and treatment strategy for SMR. Abbreviation: AHA, American Heart Association; ACC, American College of cardiology; AF, atrial fibrillation; CAD, coronary artery disease; Cath; catheterism; CMR, cardiac magnetic resonance; EROA, effective regurgitant orifice area; ESC, European Society of Cardiology; GDMT, guideline-directed medical therapy; IE, infective endocarditis; LA, left atrium; LV, left ventricle; PAPS, pulmonary artery systolic pressure; RF, regurgitant fraction; RVol, regurgitant volume; SMR, secondary mitral regurgitation; TEE, transoesophageal echocardiography, TEER, transcatheter edge to edge repair; TR, tricuspid regurgitation. From Vahanian, et al. [1]; Otto CM, et al. [2]; Iung B, et al. [11]; Nishimura RA, et al. [14]; Chambers JB, et al. [34].

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  Fig. 2.. Qualitative and Quantitative Parameters for Standardized Echo Reporting in patient with SMR. Abbreviations in other figures. From Baumgartner H, et al. [10]; Zoghbi WA, et al. [15]; Zoghbi WA, et al. [16]; Chambers JB, et al. [34].

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  Fig. 3.. Treatment option for secondary mitral regurgitation. Abbreviation: CABG, coronary artery bypass grafting; CRT, cardiac resynchronization; HF, heart failure; LAVD, left ventricle assistance device; LV, left ventricle; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; MV, mitral valve MVR, mitral valve repair; RMA, restrictive mitral annuloplastie; SVR, subannular repair; TEER, transcatheter edge to edge repair. Others abbreviation in Fig. 1. From Vahanian, et al. [1]; Otto CM, et al. [2]; Stone GW, et al. [23]; Petrus AHJ, et al. [39]; Harmel EK, et al. [40]; Nappi F, et al. [41]; Acker MA, et al. [42]; Obadia JF, et al. [43]; Iung B, et al. [44].

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  Fig. 4.. Class of recommendation (COR) and the level of evidence (LOE) that direct the degree of choice for a treatment. 2020 ACC/AHA guidelines and 2021 ESC guidelines elaborated very scarce recommendations for secondary mitral regurgitation that are based on Classe of Recommandation 1 (COR 1) and Level of Evidence (LOE) A in ACC/AHA and the guidelines. Abbreviations: COR, Classe of Recommandation; LOE, Level of Evidence; SMR, secondary mitral regurgitation. From Vahanian, et al. [1]; Otto CM, et al. [2].

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  Fig. 5.. Multimodality echocardiographic imaging of secondary ischemic mitral regurgitation. A 70 y-old patient presenting with ischemic cardiomyopathy and LVEF at 25%. Three-vessel disease including right coronary occlusion has been diagnosed. TTE parasternal long axis view (A) and TEE LVOT view (B) show eccentric jet of MR due to asymmetrical tethering. (C) 3D TEE- en face view from LA showed marked indentations between P2-P3 and P2-P1 (white arrow) due to LV remodeling. (D) 3D TEE- en face view from LV showing an apical and posterior displacement of posterior papillary muscle (white arrow) secondary to localized LV remodeling. (E,F) MVQ software permits a reconstruction and modalisation of mitral valve, showing here a defect in the coaptation of mitral leaflets due to a tethering of the posterior valve induced by LV remodeling. Abbreviation: Ao, aortic; AL; anterior leaflet; A1,2,3 anterior scallop of MV; P1,2,3 posterior scallop of MV; PPM, posterior papillary muscle.

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  Fig. 6.. Recommendations on indications for mitral valve intervention. (Left) 2020 ACC/AHA guidelines. (Right) 2021 ESC guidelines. Abbreviation: PCI, percutaneous coronary intervention; TAVI, trancatheter aortic valve implantation. From Vahanian, et al. [1]; Otto CM, et al. [2]. Others abbreviation in Fig. 1.

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  Fig. 7.. TEER in patient with ischemic SMR. 3D-TEE (A) and 3d-TEE color (B) en-face view showing central ischemic secondary MR. (C) 3D-TEE e-face view after a successful procedure with implantation of 2 central Mitraclips. (D) TTE 3-chamber view showing persistent good results at 1 year with residual mild MR and no hemodynamic stenosis (mean transmitral gradient at 4 mmHg).

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  Fig. 8.. Depicts the treatment algorithm for patients with severe secondary MR undergoing MV surgery. Patients with severe secondary MR receive either isolated RMA or RMA combined with subannular repair and coronary artery bypass operation. Preoperative echocardiographic markers for recurrent MR evaluate the result of MV repair after undersized restrictive ring annuloplasty (Up red arrow). Preoperative echocardiographic markers for recurrent MR evaluate the result of MV repair after the use of combined of RMA and PMA (down red arrow). Abbreviations: PMA, papillary muscle approximation. Others abbreviation in previous figures. From Petrus AHJ, et al. [39]; Harmel EK, et al. [40]; Nappi F, et al. [41, 86, 87, 88, 89, 90, 91, 92]; Acker MA, et al. [42]; Michler RE, et al. [98].