Secondary regurgitation
Mitral regurgitation is a predictor of mortality independent of LV function when moderate or worse (effective regurgitant orifice area ≥20 mm2). The regurgitation is cause by tenting of the mitral leaflets as a result of abnormal tension on the chordae and the surgical aim is to offset this with a small annuloplasty ring to reduce the annulus diameter (see figure 19).
Echocardiographic features favouring mitral repair are given in Figure 20 and table 5.
Good results are reported but the risks may be high. The decision for surgery depends on whether there is evidence of viability and whether revascularisation is feasible:
CABG being performed electively
- Moderate (regurgitant orifice area ≥20 mm2) and LVEF >30% (class I)
- Mild (regurgitant orifice area <20 mm2) (class IIa)
CABG not indicated for chest pain
- LVEF <30% with evidence of viability and if revascularisation is feasible (class IIa)
- As a last resort if full medical therapy including cardiac resynchronisation therapy (CRT) fails if there is severe MR and with LVEF >30% (class IIb). This group may be considered for a Mitraclip™ or other transcatheter procedure.
Tricuspid valve disease
Surgery is indicated for symptomatic severe tricuspid stenosis. The indications and timing of surgery for tricuspid regurgitation are uncertain. It is difficult to judge whether tricuspid regurgitation will improve as the PA pressure falls consequent on surgery for left-sided disease. However often there is insufficient improvement or, in the presence of initially minor rheumatic changes, there is progression of disease. In general therefore surgery should be performed at the time of left sided surgery if there is:
- Moderate or severe tricuspid regurgitation (having mitral surgery for prolapse or mild or worse tricuspid regurgitation [rheumatic disease])
- A dilated tricuspid annulus (≥40 mm)
Surgery (usually tricuspid annuloplasty) is also indicated with severe primary tricuspid regurgitation for:
- Symptoms (Class I)
- Progressive RV dilatation (Class IIa)
Conclusion
The decision to undertake surgery may be quite straightforward in patients with symptoms of severe heart valve disease, particularly valvular stenosis. However, it is much less clear-cut for patients with severe but asymptomatic defects, or those with severe symptoms and only mild to moderate defects. While ESC and other guidelines provide a general framework for decision making, each case requires a tailored approach, taking into account, the patients overall health status, his or her wishes, the level of complexity and the challenges posed by the individual valvular disorder.
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References
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Suggested further reading
Lancellotti P, Moura L, Pierard LA, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr 2010;11:307–32. http://dx.doi.org/10.1093/ejechocard/jeq031
Chikwe J, Cooke DT, Weiss A. Oxford specialist handbooks in surgery – cardiothoracic surgery. Oxford University Press, Second Edition 2013. ISBN 978-0-19-964283-0
Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988;60:299–308. http://dx.doi.org/10.1136/hrt.60.4.299
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