|Valve Morphology||Flail leaflets or ruptured papillary muscles are specific for severe MR||Other findings are non-specific|
|Regurgitant Color Flow||Easy to use, evaluates spatial orientation of MR jet, differentiates mild versus severe||Subject to technical and hemodynamic variation; can be underestimated with wallimpinging jets; image quality dependent|
|Vena Contracta Width||Quick and easy to use; independent of hemodynamic and instrumentation factors; applies to eccentric jets; can differentiate mild versus severe MR||Not applicable to multiple jets; intermediate values require confirmation; small measurement errors can lead to big changes; 2D measure of a 3D structure; limited lateral resolution|
|Proximal Isovelocity Surface Area (PISA)||Can be applied to eccentric jets (when angle corrected); not affected by etiology of MR; quantitative: provides both lesion severity (EROA) and volume data (R Vol)||Not valid with multiple jets; provides peak flow and maximal EROA; inter-observer variability; errors in radius measurement are squared; multiple potential sources of measurement error|
|Flow Quantitation–PW||Quantitative; valid in multiple jets and eccentric jets; provides both lesion severity (EROA, RF) and volume data (RVol)||Time consuming; measurement of flow at MV annulus less reliable with calcified MV and/or annulus; not valid with concomitant significant AR unless pulmonic site is used;requires measurement at multiple sites, which introduces errors|
Simple, readily available
Easy assessment of MR timing
|Qualitative; complementary data; complete signal difficult to obtain in eccentric jet; gain dependent|
|Peak Mitral E Velocity||Simple, readily available, A-wave dominance excludes severe MR||Influenced by LA pressure/compliance, LV relaxation, MV area, and AF; complementary data only, does not quantify MR severity|
|Pulmonary Vein Flow||Simple; systolic flow reversal is specific for severe MR||Influenced by LA pressure, AF; not accurate if MR jet directed into the sampled vein; absence does not rule out severe MR|
|LA and LV Size||Enlargement sensitive for chronic severe MR, important for outcomes; normal size virtually excludes severe chronic MR||Enlargement seen in other conditions (non-specific); may be normal in acute severe MR|
|Primary Mitral Regurgitation|
Non-resection techniques using either polytetrafluorethylene (PTFE) neochord reconstruction or ipsilateral chordal transfer from secondary to primary position, with annuloplasty ring
Focal triangular resection with annuloplasty ring
Sliding leaflet valvuloplasty with annuloplasty ring
|Secondary Mitral Regurgitation|
Restrictive remodeling rigid annuloplasty ring
Chord-sparing mitral valve replacement
|Ideal Pathoanatomy||Challenging Pathoanatomy||Relative Pathoanatomic Contraindications|
|Primary Lesion Location||Posterior Leaflet only||Anterior Leaflet or Bi-leaflet||None|
|Leaflet calcification||None||Mild||Moderate to severe|
|Annular calcification||None||Mild to moderate with minimal leaflet encroachment||Severe or with significant leaflet encroachment|
|Subvalvular Apparatus||Thin, normal||Mild diffuse thickening or moderate focal thickening||Severe and diffuse thickening with leaflet retraction|
|Mechanism of MR||Type II fibroelastic deficiency or focal myxomatous prolapse or flail||Type II forme fruste or bileaflet myxomatous (Barlow’s) disease; Type I healed or active endocarditis; Type III A/B with mild restriction or leaflet thickening||Type IIIB with severe tethering and inferobasal aneurysm; Type IIIA with severe bileaflet calcification, Type I active infection with severe leaflet or annular tissue destruction|
|Unique Anatomic Complexities||None||Redo cardiac operation or mitral re-repair; anatomic predictors of systolic anterior motion (i.e. septal hypertrophy); adult congenital anomalies; focal papillary muscle rupture||Mitral valve reoperation with paucity of leaflet tissue; diffuse radiation valvulopathy; papillary muscle rupture with shock|
|Favorable Features*||Less or Unfavorable Features*|
|Location of Leaflet Pathology||Noncommissural pathology (Medial, middle, lateral segments).||Commissural segments, leaflet perforations or clefts|
|Calcification||None or minimal calcification||Severe leaflet calcification or calcification in area of grasping zone
Severe annular calcification
|Mean MV gradient||Transmitral gradient < 4 mm||Mitral stenosis (rheumatic or calcific; mean mitral gradient > 5 mmHg)|
|Mitral valve area||MVA ≥ 4.0 cm2||MVA < 4.0 cm2|
|Grasping Zone length||> 10 mm||< 7 mm|
|Primary MR||Flail width < 15 mm; flail gap < 10 mm; single segment pathology
Normal leaflet thickness
|Flail width > 15 mm and flail gap > 10 mm
Multi-segment pathology; highly mobile flail leaflet with multiple ruptured chords
Severely and diffusely thickened (5 mm in diastole) and redundant leaflets (Barlow's type valve); LVESD > 55 mm
|Secondary MR||Coaptation depth < 11 mm; coaptation length (overlap length) ≥ 2mm||LVESD > 70 mm|
Bonow RO, O’Gara PT, Adams DH, Badhwar V, Bavaria JE, Elmariah S, Hung JW, Lindenfeld J, Morris AA, Satpathy R, Whisenant B, Woo YJ, 2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation, Journal of the American College of Cardiology (2020), doi: https:// doi.org/10.1016/j.jacc.2020.02.005
O’Gara PT, Grayburn PA, Badhwar V, Afonso LC, Carroll JD, Elmariah S, Kithcart AP, Nishimura RA, Ryan T, Schwartz A, Stevenson LW. 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathway.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O’Gara PT, Rigolin VH, Sundt TM, Thompson A. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J AM Coll Cardiol 2017: DOI: 10.1016/j.jacc.2017.03.011
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J AM Coll Cardiol 2014:63;57-185
Nishimura RA, O’Gara PT, Bavaria JE, Brindis RG, Carroll JD, Kavinsky CJ, Lindman BR, Linderbaum JA, Little SH, Mack MJ, Mauri L, Miranda WR, Shahian DM, Sundt TM 3rd. 2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: a proposal to optimize care for patients with valvular heart disease: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2019;73:2609–35
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ManageMR provides clinicians with personalized referral and treatment advice for patients diagnosed with mitral regurgitation by verifying the severity and etiology of the MR. For optimal use:
The information and recommendations in this App are meant to support clinical decision making. They are not meant to represent the only or best course of care, or replace clinical judgment. Therapeutic options should be determined after discussion between the patient and their care provider.
The content for this App is derived from the 2020 ACC Focused Update to the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation. App content and design was further refined and vetted by ACC member clinicians, and through user testing with clinicians practicing in relevant specialties.
This app was developed as part of a continuing initiative to enable clinicians to access and implement ACC clinical policy at the point of care for better patient care and outcomes. Previous versions of the app were developed as part of the ACC's Emerging Mitral Regurgitation Clinical Care (EMC2) Initiative, and was supported by Founding Sponsor Abbott Vascular. All content was independently developed with no sponsor involvement.
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