Defining "severe" secondary mitral regurgitation: Emphasizing an integrated approach

Paul A. Grayburn; Blasé Carabello; Judy Hung; Linda D. Gillam; David Liang; Michael J. Mack; Patrick M. McCarthy; D. Craig Miller; Alfredo Trento; Robert J. Siegel

doi:10.1016/j.jacc.2014.10.016

Defining "severe" secondary mitral regurgitation: Emphasizing an integrated approach

Paul A. Grayburn^*, Blasé Carabello, Judy Hung, Linda D. Gillam, David Liang, Michael J. Mack, Patrick M. McCarthy, D. Craig Miller, Alfredo Trento, Robert J. Siegel

^*Corresponding author for this work

Surgery, Cardiac Surgery Division

Research output: Contribution to journal › Review article › peer-review

173 Scopus citations

Abstract

Secondary mitral regurgitation (MR) is associated with poor outcomes, but its correction does not reverse the underlying left ventricular (LV) pathology or improve the prognosis. The recently published American Heart Association/American College of Cardiology guidelines on valvular heart disease generated considerable controversy by revising the definition of severe secondary MR from an effective regurgitant orifice area (EROA) of 0.4 to 0.2 cm², and from a regurgitant volume (RVol) of 60 to 30 ml. This paper reviews hydrodynamic determinants of MR severity, showing that EROA and RVol values associated with severe MR depend on LV volume. This explains disparities in the evidence associating a lower EROA threshold with suboptimal survival. Redefining MR severity purely on EROA or RVol may cause significant clinical problems. As the guidelines emphasize, defining severe MR requires careful integration of all echocardiographic and clinical data, as measurement of EROA is imprecise and poorly reproducible.

Original language	English (US)
Pages (from-to)	2792-2801
Number of pages	10
Journal	Journal of the American College of Cardiology
Volume	64
Issue number	25
DOIs	https://doi.org/10.1016/j.jacc.2014.10.016
State	Published - Dec 30 2014

Funding

Dr. Grayburn has received grant support from Abbott Vascular and Medtronic ; has served as a consultant for Abbott Vascular, Tendyne, and Bracco Diagnostics; and has had Echo Core Lab contracts for ValTech Cardio, Guided Delivery Systems, and Tendyne. Dr. Gillam has had Core Lab Research contracts for Edwards Lifesciences and Medtronic. Dr. Liang serves on the medical advisory board for and has received research support from Philips Healthcare . Dr. McCarthy has served as a consultant for Edwards Lifesciences; and is an inventor of IMR ETlogix. Dr. Miller has served on the PARTNER Executive Committee for Edwards Lifesciences; has served as a consultant for Medtronic CardioVascular Division and Abbott Vascular Structural Heart (MitraClip); has served on the scientific advisory board for GenTAC. Dr. Siegel has served as a speaker for Philips and Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Gerald Maurer, MD, served as Guest Editor for this paper.

Keywords

echocardiography
guidelines
hemodynamics
mitral valve
mitral valve insufficiency

ASJC Scopus subject areas

Cardiology and Cardiovascular Medicine

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10.1016/j.jacc.2014.10.016

Cite this

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title = "Defining {"}severe{"} secondary mitral regurgitation: Emphasizing an integrated approach",

abstract = "Secondary mitral regurgitation (MR) is associated with poor outcomes, but its correction does not reverse the underlying left ventricular (LV) pathology or improve the prognosis. The recently published American Heart Association/American College of Cardiology guidelines on valvular heart disease generated considerable controversy by revising the definition of severe secondary MR from an effective regurgitant orifice area (EROA) of 0.4 to 0.2 cm2, and from a regurgitant volume (RVol) of 60 to 30 ml. This paper reviews hydrodynamic determinants of MR severity, showing that EROA and RVol values associated with severe MR depend on LV volume. This explains disparities in the evidence associating a lower EROA threshold with suboptimal survival. Redefining MR severity purely on EROA or RVol may cause significant clinical problems. As the guidelines emphasize, defining severe MR requires careful integration of all echocardiographic and clinical data, as measurement of EROA is imprecise and poorly reproducible.",

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author = "Grayburn, {Paul A.} and Blas{\'e} Carabello and Judy Hung and Gillam, {Linda D.} and David Liang and Mack, {Michael J.} and McCarthy, {Patrick M.} and Miller, {D. Craig} and Alfredo Trento and Siegel, {Robert J.}",

note = "Funding Information: Dr. Grayburn has received grant support from Abbott Vascular and Medtronic ; has served as a consultant for Abbott Vascular, Tendyne, and Bracco Diagnostics; and has had Echo Core Lab contracts for ValTech Cardio, Guided Delivery Systems, and Tendyne. Dr. Gillam has had Core Lab Research contracts for Edwards Lifesciences and Medtronic. Dr. Liang serves on the medical advisory board for and has received research support from Philips Healthcare . Dr. McCarthy has served as a consultant for Edwards Lifesciences; and is an inventor of IMR ETlogix. Dr. Miller has served on the PARTNER Executive Committee for Edwards Lifesciences; has served as a consultant for Medtronic CardioVascular Division and Abbott Vascular Structural Heart (MitraClip); has served on the scientific advisory board for GenTAC. Dr. Siegel has served as a speaker for Philips and Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Gerald Maurer, MD, served as Guest Editor for this paper. Publisher Copyright: {\textcopyright} 2014 American College of Cardiology Foundation.",

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T2 - Emphasizing an integrated approach

AU - Grayburn, Paul A.

AU - Carabello, Blasé

AU - Hung, Judy

AU - Gillam, Linda D.

AU - Liang, David

AU - Mack, Michael J.

AU - McCarthy, Patrick M.

AU - Miller, D. Craig

AU - Trento, Alfredo

AU - Siegel, Robert J.

N1 - Funding Information: Dr. Grayburn has received grant support from Abbott Vascular and Medtronic ; has served as a consultant for Abbott Vascular, Tendyne, and Bracco Diagnostics; and has had Echo Core Lab contracts for ValTech Cardio, Guided Delivery Systems, and Tendyne. Dr. Gillam has had Core Lab Research contracts for Edwards Lifesciences and Medtronic. Dr. Liang serves on the medical advisory board for and has received research support from Philips Healthcare . Dr. McCarthy has served as a consultant for Edwards Lifesciences; and is an inventor of IMR ETlogix. Dr. Miller has served on the PARTNER Executive Committee for Edwards Lifesciences; has served as a consultant for Medtronic CardioVascular Division and Abbott Vascular Structural Heart (MitraClip); has served on the scientific advisory board for GenTAC. Dr. Siegel has served as a speaker for Philips and Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Gerald Maurer, MD, served as Guest Editor for this paper. Publisher Copyright: © 2014 American College of Cardiology Foundation.

PY - 2014/12/30

Y1 - 2014/12/30

N2 - Secondary mitral regurgitation (MR) is associated with poor outcomes, but its correction does not reverse the underlying left ventricular (LV) pathology or improve the prognosis. The recently published American Heart Association/American College of Cardiology guidelines on valvular heart disease generated considerable controversy by revising the definition of severe secondary MR from an effective regurgitant orifice area (EROA) of 0.4 to 0.2 cm2, and from a regurgitant volume (RVol) of 60 to 30 ml. This paper reviews hydrodynamic determinants of MR severity, showing that EROA and RVol values associated with severe MR depend on LV volume. This explains disparities in the evidence associating a lower EROA threshold with suboptimal survival. Redefining MR severity purely on EROA or RVol may cause significant clinical problems. As the guidelines emphasize, defining severe MR requires careful integration of all echocardiographic and clinical data, as measurement of EROA is imprecise and poorly reproducible.

AB - Secondary mitral regurgitation (MR) is associated with poor outcomes, but its correction does not reverse the underlying left ventricular (LV) pathology or improve the prognosis. The recently published American Heart Association/American College of Cardiology guidelines on valvular heart disease generated considerable controversy by revising the definition of severe secondary MR from an effective regurgitant orifice area (EROA) of 0.4 to 0.2 cm2, and from a regurgitant volume (RVol) of 60 to 30 ml. This paper reviews hydrodynamic determinants of MR severity, showing that EROA and RVol values associated with severe MR depend on LV volume. This explains disparities in the evidence associating a lower EROA threshold with suboptimal survival. Redefining MR severity purely on EROA or RVol may cause significant clinical problems. As the guidelines emphasize, defining severe MR requires careful integration of all echocardiographic and clinical data, as measurement of EROA is imprecise and poorly reproducible.

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KW - guidelines

KW - hemodynamics

KW - mitral valve

KW - mitral valve insufficiency

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JO - Journal of the American College of Cardiology

JF - Journal of the American College of Cardiology

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ER -

Defining "severe" secondary mitral regurgitation: Emphasizing an integrated approach

Abstract

Funding

Keywords

ASJC Scopus subject areas

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