ACC Unveils Consensus Document to Help Guide Management of Mitral Regurgitation

Cardiologists and other health professionals tasked with handling chronic mitral regurgitation (MR) have a new tool to help manage patients with this complex condition.

The American College of Cardiology has released an expert consensus decision pathway, written by a committee chaired by Patrick O’Gara, MD (Brigham and Women’s Hospital, Boston, MA), that guides clinicians from the initial evaluation of patients with chronic MR to the various treatment options.

Vinay Badhwar, MD (West Virginia University, Morgantown), one of the vice chairs of the writing committee, described the pathway, published online October 18, 2017, ahead of print in the Journal of the American College of Cardiology, as a “guideline-enhancement document,” noting that there are challenges associated with penetration of guidelines into clinical practice.

“Our hope is that we will see more patients appropriately diagnosed . . . and then appropriately triaged for care because we know that in some pathologic states of mitral regurgitation that earlier intervention and management is very important for the patient’s longevity,” he told TCTMD. “And we hope that this document helps along that pathway.”

The pathway, which uses the 2014 guidelines for the management of valvular heart disease and the 2017 focused update as a foundation, starts with a focus on appropriate diagnosis confirmed with echocardiography and determination of the mechanism, etiology, and severity of MR, with tables and flow charts included to help that process. For example, there is a decision tree that can be used to differentiate primary from secondary MR and a table detailing qualitative and quantitative parameters for standardized echocardiographic reporting.

From there, the document moves into management and referral pathways, with additional flow charts and tables. For treatment, which can include medical therapy, surgery, or transcatheter approaches, “there’s added nuance provided on the surgical side on the complexities of valve repair and the types of valve repair solutions for certain pathoanatomic findings,” Badhwar said.

The authors highlight the narrow role for transcatheter approaches to treating MR. “Current use of transcatheter edge-to-edge repair in the United States is limited to symptomatic patients with primary, severe MR who are poor operative candidates,” they write. “Other transcatheter mitral valve repair and replacement systems are under active investigation.”

The document also underscores the importance of a multidisciplinary heart valve team consisting of surgeons, interventionalists, imaging experts, and others, stating that a treatment recommendation coming from the team should be discussed with patients and their families in a shared decision-making process. Additionally, the heart valve team should maintain ongoing communication with the referring physician throughout a patient’s course of treatment.

And finally, the authors say, “Long-term follow-up of patients after surgical or transcatheter intervention is essential for assessment of durability, functional outcomes, and survival.”