Updated AATS Guidelines Help Cardiovascular Surgeons Navigate the Challenges of Managing Ischemic Mitral Regurgitation

AATS Guidelines presented in The Journal of Thoracic and Cardiovascular Surgery offer clear recommendations for treating a complicated condition about which limited long-term data exist

Article ID: 673095

Released: 17-Apr-2017 3:30 PM EDT

Source Newsroom: American Association for Thoracic Surgery (AATS)

  • Credit: The Journal of Thoracic and Cardiovascular Surgery

    Illustrated mechanism of IMR. Apically displaced leaflet coaptation with restricted leaflet closure results in MR. MR, Mitral regurgitation; AoV, aortic valve.

Newswise — Beverly, MA, April 17, 2017 – Mitral regurgitation can occur in up to 50% of patients with ischemic heart disease and even mild ischemic mitral regurgitation (IMR) has been linked to increased long-term mortality. How best to treat IMR is controversial, in part, because of the fragility and complexity of the patients, difficulty of grading IMR, the variety of medical and surgical options, and lack of long-term quality studies. Noting that other guidelines generally do not focus on optimal surgical approaches to IMR, the AATS enlisted a group of experts to create a consensus document to provide clinicians with their recommendations based on their opinions and the best available evidence. The Guidelines are published in The Journal of Thoracic and Cardiovascular Surgery, the official publication of the American Association for Thoracic Surgery (AATS).

“We acknowledge that ischemic MR remains a challenging situation for the clinician and surgeon. However, emerging data has provided an opportunity for more guided recommendations for this patient population. These Guidelines will continue to evolve as more data is reported in the future,” commented Irving L. Kron, MD, Professor of Surgery at the University of Virginia School of Medicine and chair of the AATS IMR Consensus Guidelines Writing Committee.

An example of what the Guidelines offer is a section on whether to repair or replace the mitral valve in severe IMR – a very controversial issue. While guidelines from the American Heart Association/American College of Cardiology and the European Society of Cardiology/European Association for CardioThoracic Surgery recommend mitral valve surgery for patients with severe IMR who remain symptomatic despite optimal medical treatment, they “provide no guidance in selecting MV replacement versus MV repair,” explained Dr. Kron.

These new Guidelines suggest that replacement for patients with severe IMR who have a basal aneurysm (dyskinesis), significant echocardiographic evidence of leaflet tethering, or moderate to severe left ventricular remodeling (left ventricular end-diastolic diameter >65mm) is a reasonable therapy. Repair, rather than replacement, can also be considered for those who do not have a basal aneurysm/dyskinesis, significant leaflet tethering, or severe LV enlargement.

For patients with moderate IMR, these guidelines say MV repair can be considered at the time of coronary artery bypass grafting. Coronary bypass alone is usually sufficient. Additional sections of the document are devoted to optimizing IMR imaging and whether to use percutaneous transcatheter MV repair.

Mitral regurgitation is blood leakage through the mitral valve into the left atrium. It can be the result of damage to the valve itself or ischemic damage to left ventricular heart muscle, for example following myocardial infarction. IMR can lead to elevated left atrial blood pressure and volume, pulmonary hypertension, and fluid build-up in the lungs. Patients with IMR can experience chest pain and palpitations, shortness of breath, fatigue, weakness, lightheadedness, and swelling of the ankles, feet, and abdomen, and the possibility of heart failure, atrial fibrillation, and death.

“These Guidelines reflect the efforts of a panel of experts, drawing on expert opinion among other modalities, and are based on what we know at this time,” remarked Dr. Kron. “There is no doubt that the Guidelines will continue to evolve as reports of longer-term follow-up emerge.”

 

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NOTES FOR EDITORS

“2016 Update to the American Association for Thoracic Surgery (AATS) Consensus Guidelines: Ischemic Mitral Valve Regurgitation (IMR),” by the AATS Ischemic Mitral Regurgitation Consensus Guidelines Writing Committee: Irving L. Kron, MD, Damien J. LaPar, MD, MSc, Michael A. Acker, MD, David H. Adams, MD, Gorav Ailawadi, MD, Steven F. Bolling, MD, Judy W. Hung, MD, D. Scott Lim, MD, Michael J. Mack, MD, Patrick T. O’Gara, MD, Michael K. Parides, PhD, and John D. Puskas, MD (DOI: http://dx.doi.org/10.1016/j.jtcvs.2017.01.031). It will be published in The Journal of Thoracic and Cardiovascular Surgery, Volume 153, Issue 5 (May 2017), published by Elsevier.

Full text of these Guidelines is available to credentialed journalists upon request; contact Lisa McEvoy, Director of Marketing and Communications, American Association for Thoracic Surgery, at +1 978-252-2200, Ext. 521 or lmcevoy@aats.org. To reach the AATS committee for comment, contact Irving L. Kron, MD, at +1 434-924-2158 or ILK@hscmail.mcc.virginia.edu.

ABOUT THE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY

The Journal presents original, exclusive articles on conditions of the chest, heart, lungs, and great vessels where surgical intervention is indicated. An official publication of the American Association for Thoracic Surgery and the Western Thoracic Surgical Association, the journal focuses on techniques and developments in cardiac surgery, lung and esophageal surgeries, heart and lung transplantation, and other procedures. Published by Elsevier, it has a current Impact Factor of 3.494 (2015 Journal Citation Reports, ©2016 Thomson Reuters). www.jtcvsonline.org

ABOUT THE AMERICAN ASSOCIATION FOR THORACIC SURGERY (AATS)

The American Association for Thoracic Surgery (AATS) is an international organization of over 1,300 of the world’s foremost thoracic and cardiothoracic surgeons, representing 41 countries. AATS encourages and stimulates education and investigation into the areas of intrathoracic physiology, pathology and therapy. Founded in 1917 by a respected group of the last century’s earliest pioneers in the field of thoracic surgery, the AATS’ original mission was to “foster the evolution of an interest in surgery of the Thorax.”

As it celebrates its centennial anniversary, the AATS continues to be the premiere association among cardiothoracic surgeons. The purpose of the Association is the continual enhancement of the ability of cardiothoracic surgeons to provide the highest level of quality patient care. To this end, the AATS encourages, promotes, and stimulates the scientific investigation and study of cardiothoracic surgery. Visit www.aats.org

 

 


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