What’s New in ACC/AHA Valve Guidelines 2014: Mitral Regurgitation

What’s New in ACC/AHA Valve 
Guidelines 2014: 
Mitral Regurgitation 
A/Prof Yeo Khung Keong 
MBBS, ABIM (Internal Medicine, Cardiology, Interventional 
Cardiology), ABVM (Vascular Medicine, Endovascular), FAMS, FACC, 
FSCAI 
Senior Consultant, Cardiology 
National Heart Centre Singapore 
Adjunct Associate Professor 
Duke-NUS Graduate Medical School 
Valve Guidelines 
First guidelines in 1996 revised in 1998 
2nd major revision 2006 with minor revision 2008 
ESC guidelines 2013 
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Major changes 
Stage system 
• Reflects valve severity, effect on LV and symptoms 
• Valve specific changes 
• Adds the role of expertise and “Heart Valve Centre of 
Excellence” 
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Reviewers 
2 official reviewers: ACC and the AHA 
1 reviewer each from the American Association for Thoracic Surgery, ASE, 
Society for Cardiovascular Angiography and Interventions, Society of 
Cardiovascular Anesthesiologists, and STS 
39 individual content reviewers (which included representatives from the 
following ACC committees and councils: Adult Congenital and Pediatric 
Cardiology Section, Association of International Governors, Council on Clinical 
Practice, Cardiovascular Section Leadership Council, Geriatric Cardiology 
Section Leadership Council, Heart Failure and Transplant Council, 
Interventional Council, Lifelong Learning Oversight Committee, Prevention of 
Cardiovascular Disease Committee, and Surgeon Council). 
Approved for publication by ACC and AHA and endorsed by the AATS, ASE, 
SCAI, Society of Cardiovascular Anesthesiologists, and STS 
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Intervention 
Indication for intervention is dependent on: 
• Presence or absence of symptoms; 
• The severity of VHD; 
• Response of the LV and/or RV to the volume or pressure 
overload caused by VHD; 
• The effect on the pulmonary or systemic circulation; and 
• A change in heart rhythm 
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Stages 
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Rationale 
• The purpose of valvular intervention is to improve symptoms 
and/or prolong survival, as well as to minimize the risk of 
VHD-related complications such as asymptomatic irreversible 
ventricular dysfunction, pulmonary hypertension, stroke, and 
atrial fibrillation (AF) 
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Heart Valve Team 
• Management best achieved by a Heart Valve Team composed 
primarily of a cardiologist and surgeon (including a structural valve 
interventionist if a catheter-based therapy is being considered) 
• Multidisciplinary; including cardiologists, structural valve 
interventionalists, cardiovascular imaging specialists, cardiovascular 
surgeons, anesthesiologists, and nurses 
• Optimize patient selection through a comprehensive understanding 
of the risk–benefit ratio of different treatment strategies 
• Shared informed, decision-making approach with patient and family 
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Heart Valve Centres of Excellence 
• Composed of experienced healthcare providers with expertise 
from multiple disciplines 
• Offer all available options for diagnosis and management, 
including complex valve repair, aortic surgery, and 
transcatheter therapies 
• Participate in regional or national outcome registries; 
• Demonstrate adherence to national guidelines 
• Participate in continued evaluation and quality improvement 
processes to enhance patient outcomes 
• Publicly report their available mortality and success rates 
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Mitral Regurgitation 
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Secondary (Functional MR) 
• Optimal medical tx first 
• Biventricular pacing first if indicated 
• MV surgery if going for cardiac surgery (eg. CABG) 
• Limited utility of surgery (IIB) 
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Optimal Timing of Intervention: Stage C 
• Current approaches to identifying the optimal timing of 
intervention in patients with progressive valve disease are 
suboptimal 
• Symptom onset is a subjective measure and may occur too late 
in the disease course for optimal long-term outcomes 
• Recommendations rely only on simple linear dimensions used in 
published series with data that may not reflect contemporary 
clinical outcomes 
• However, LV enlargement and dysfunction are late 
consequences of valve dysfunction 
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Better Options for Intervention: Stage D 
• Moderate-to-severe VHD is present in 2.5% of the U.S. 
population a 
• 4% and 9% of those 65 to 75 years of age 
• 12% to 13% of those >75 years of age 
• However, even with intervention, overall survival is lower than 
expected, and the risk of adverse outcomes due to VHD is 
high, both because of limited options for restoring normal 
valve function and failure to intervene at the optimal time 
point in the disease course 
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Summary 
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• New staging system 
• New valve criteria 
• Symptoms 
• Cardiac dysfunction 
• Repair better than Replacement 
• Heart valve surgery outcomes 
• Percutaneous option for first time 
• Heart teams and Heart valve centres of excellence