Secondary Mitral Regurgitation

Question 1

Pathophysiology of Chronic Secondary MR

Answer 1

In chronic secondary MR, the mitral valve leaflets and
chords usually are normal or minimally thickened. Instead,
MR is associated with severe LV dysfunction
caused by CAD (ischemic chronic secondary MR) or idiopathic
myocardial disease (nonischemic chronic secondary
MR). The abnormal and dilated LV causes papillary
muscle displacement, which in turn results in leaflet
tethering with associated annular dilation that prevents
adequate leaflet coaptation.

Question 2

Severe Secondary MR Hemodynamics

Answer 2

ERO ≥0.40 cm2
Regurgitant volume ≥60 mL
Regurgitant fraction ≥50%

Question 3

Recommendations for Intervention for Secondary MR Using TEER

Answer 3

chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent symptoms (NYHA class II, III, or IV) while on optimal GDMT for HF (Stage D), TEER is reasonable in patients with:
1. appropriate anatomy as defined on TEE
2. LVEF between 20% and 50%,
3. LVESD ≤70mm
4. pulmonary artery systolic pressure ≤70 mm Hg.

Question 4

Recommendations for Surgical Intervention for Secondary MR

Answer 4

1. In patients with severe secondary MR (Stages C and D), mitral valve surgery is reasonable when CABG is undertaken for the treatment of myocardial ischemia.
2. In patients with chronic severe secondary MR from atrial annular dilation with preserved LV systolic function (LVEF ≥50%) who have severe persistent symptoms (NYHA class III or IV) despite therapy for HF and therapy for associated AF or other comorbidities (Stage D)
3. In patients with chronic severe secondary MR related to LV systolic dysfunction (LVEF <50%) who have persistent severe symptoms (NYHA class III or IV) while on optimal GDMT for HF (Stage D),