MY APPROACH
MY APPROACH to the surgeon’s view on degenerative mitral regurgitation*

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Part I: What the surgeon needs from the echocardiogram

When I am asked to evaluate a patient with severe mitral regurgitation for surgical intervention, the first thing that I think about is whether we have enough information to decide if the regurgitation is primary (degenerative), secondary (functional), or a combination of both. These entities represent different disease processes, have different treatment approaches, and markedly different prognoses; so, it is very important to distinguish them at the outset. As a surgeon, I often have two

Accurate assessment of ventricular function

  • Assessment of the ejection fraction (EF), including quantitation; making sure that the left ventricle is not foreshortened is very important. It is important to emphasize, however, that abnormal EF in the setting of severe mitral regurgitation is defined as <60%; so, a patient with an EF of 55%, for example, does not have a normal EF. In addition, we must remember that EF is often overestimated with severe mitral regurgitation by about 10 points. So, really, by the time the EF is 55%, that

Size of the left atrium

  • Larger left atrium often reflects long-standing mitral regurgitation. A small left atrium may make the mitral valve more difficult to visualize, depending on the approach. In atrial fibrillation, very large left atrium size correlates with lower effectiveness of the Maze procedure, if performed.

Presence and severity of pulmonary hypertension

  • Severe pulmonary hypertension in a patient with significant lung disease may benefit from further investigation to establish reversibility and may prohibit the operation if not reversible.

Presence of and degree of tricuspid regurgitation

  • Higher degree of hypertension, again, often is reflective of long-standing duration of mitral regurgitation, and may require concomitant repair at the time of the mitral operation.

Finally, the inspection of the mitral valve, including all the components of the mitral valve apparatus:

  • Degree of mitral regurgitation: surgeons recognize that this can be difficult. Views that show eccentric jet wrapping around the left atrium can be very helpful. There should be an attempt to interrogate each pulmonary vein for systolic flow reversal. Similarly, there should be an attempt at quantitation of mitral regurgitation by an experienced cardiologist because inaccurate quantitation can potentially impact treatment decisions, and surgeons often do not have the intricate knowledge to

Part 2. Patient evaluation

A thorough review of the patient′s past and present history is paramount. I usually have the advantage of reviewing the information obtained by other providers, including the primary care physician and the cardiologist. There are some focused pieces of information I ask patients. Their age is important as it can impact risk; a frailty assessment is paramount; and valve choice needs to be discussed. An important gender-related issue pertains to women of childbearing age in whom a discussion on

Putting it all together

  • Does the patient have an indication for operation?

  • Is the patient a surgical candidate: what is the estimated risk—low, intermediate, high, or inoperable?

  • Is the patient frail (the old and frail patient doesn’t do well)?

  • Assuming the patient has a guideline-directed indication for surgery and he/she is an appropriate surgical risk, what is the operation—repair vs replacement?

Part 3. Surgical considerations

When I see a patient with degenerative mitral regurgitation who needs a mitral operation, the most important surgical decision is whether to repair or replace the valve. The superiority of mitral repair compared with replacement is well established in the setting of degenerative mitral regurgitation. It preserves the patient’s native valve; it avoids the risk of chronic anticoagulation; it results in better survival perioperatively and long term; it results in better preservation of ventricular

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First published on PracticeUpdate on February 23, 2016 (Part 1), February 29, 2016 (Part 2) and March 7, 2016 (Part 3). Republished with permission.

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