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Table of Contents
LETTERS TO EDITOR  
Year : 2018  |  Volume : 21  |  Issue : 4  |  Page : 464-465
Rationale for change in the criteria for defining severe ischemic mitral regurgitation in 2017 American College of Cardiology/American heart association guidelines


1 Division of Anesthesiology, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India
2 Division of Cardio-Thoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala, India

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Date of Web Publication17-Oct-2018
 

How to cite this article:
Jose RL, Varma PK. Rationale for change in the criteria for defining severe ischemic mitral regurgitation in 2017 American College of Cardiology/American heart association guidelines. Ann Card Anaesth 2018;21:464-5

How to cite this URL:
Jose RL, Varma PK. Rationale for change in the criteria for defining severe ischemic mitral regurgitation in 2017 American College of Cardiology/American heart association guidelines. Ann Card Anaesth [serial online] 2018 [cited 2018 Dec 15];21:464-5. Available from: http://www.annals.in/text.asp?2018/21/4/464/243547




Dear Editor,

This is regarding the article on ischemic mitral regurgitation (MR) by Varma et al.[1] In this article, effective regurgitant orifice area (EROA) ≥0.2 cm2, regurgitant volume (R Vol) ≥30 ml, and regurgitant fraction (RF) ≥50% were considered for the quantification of severe ischemic MR based on 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines.[2] In the 2017 focused update on valvular heart disease, the criteria for quantifying primary and secondary MR are the same, i.e., EROA ≥0.4 cm2, R Vol ≥60 ml, and RF ≥50%.[3] What is the rationale for this change?

The American Society of Echocardiography 2003 guidelines for the evaluation of valvular regurgitation highlighted the use of multiple qualitative and quantitative parameters for the quantification of severe MR rather than “eyeball” grading of color Doppler jets. Quantitative parameters for severe MR were EROA ≥0.4 cm2, R Vol ≥60 ml, and RF ≥50%.[4] The 2014 ACC/AHA guidelines redefined severe secondary MR as EROA ≥0.2 cm2, R Vol ≥30 ml, and RF ≥50%. The rationale for the changes appears to be on the basis that: (1) association of secondary MR worsens prognosis and even lower values of secondary MR can have an adverse prognosis in an already damaged left ventricle (LV) and (2) measurement of proximal isovelocity surface area (PISA) by two-dimensional Echo underestimates the true EROA due to the crescent shape of proximal convergence.[2] There were many criticisms against the lowering of the secondary MR threshold in 2014 guidelines. Secondary MR has a biphasic pattern; with the MR maximum in early systole, reaches its nadir in mid systole and again increases before mitral valve opening. Thus, single-frame measurement of EROA may not reflect the mean EROA and dynamic changes during systole. PISA radius measurement is difficult as the exact point of flow convergence may not be clear. Hence, even small errors in measurement will be squared (EROA = 2π r2 Va/Vp). A small error in measurement can result in a patient being in mild MR (Stage B) or severe secondary MR (Stage C or D).[5] A comparison of echocardiography with cardiac magnetic resonance imaging shows a tendency toward overestimating MR severity rather than underestimating it.[6] Finally, there is no convincing evidence to show that surgical- or catheter-based interventions improve survival. Therefore, lowering the threshold can lead to unnecessary interventions on the mitral valve.[7] These concerns led to a change in the current update.

EROA and R Vol are influenced by multiple factors such as LV end diastolic volume (LVEDV), LV ejection fraction, and the pressure gradient between LV and left atrium (LA). Patients can have severe MR or RF >50% (half of the stroke volume is lost into the LA) at an EROA of 0.2 cm2, particularly when LVEDV is normal. EROA of 0.4 cm2 results in RF >50% only at very large LVEDV values. This stresses the importance of considering EROA, R Vol, and RF in relation to total LV stroke volume in the assessment of MR severity. Hence, the 2017 guidelines emphasize that “EROA of >0.2 cm2 is more sensitive and >0.4 cm2 is more specific for severe MR.” It is better to defer classifying a patient as having severe secondary MR (Stage C or D) until guideline-directed medical therapy is optimized.[5] An integrative approach using multiple echocardiography parameters and clinical variables should be used to grade secondary MR severity and guide therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Varma PK, Krishna N, Jose RL, Madkaiker AN. Ischemic mitral regurgitation. Ann Card Anaesth 2017;20:432-9.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, et al. 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. Circulation 2014;129:e521-643.  Back to cited text no. 2
    
3.
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, et al. 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 Clinical Practice Guidelines. Circulation 2017;135:e1159-95.  Back to cited text no. 3
    
4.
Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16:777-802.  Back to cited text no. 4
    
5.
Grayburn PA, Carabello B, Hung J, Gillam LD, Liang D, Mack MJ, et al. Defining severe secondary mitral regurgitation: Emphasizing an Integrated Approach. J Am Coll Cardiol 2014;64:2792-801.  Back to cited text no. 5
    
6.
Uretsky S, Gillam L, Lang R, Chaudhry FA, Argulian E, Supariwala A, et al. Discordance between echocardiography and MRI in the assessment of mitral regurgitation severity: A prospective multicenter trial. J Am Coll Cardiol 2015;65:1078-88.  Back to cited text no. 6
    
7.
Grayburn PA, Stoler RC, Mack MJ. The 2017 ACC/AHA updated valve guidelines regarding mitral regurgitation: The guidelines get it right. Struct Heart 2017;1:1-2, 31-3.  Back to cited text no. 7
    

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Correspondence Address:
Praveen Kerala Varma
Division of Cardiothoracic Surgery, Amrita Institute of Medical Sciences and Research Center, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aca.ACA_51_18

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