AATS provides updated guidelines for managing ischemic mitral regurgitation

The American Association for Thoracic Surgery (AATS) released updated evidence-based guidelines for managing ischemic mitral regurgitation.

The guidelines were published online in The Journal of Thoracic and Cardiovascular Surgery on April 17.

Irving L. Kron, MD, a professor of surgery at the University of Virginia School of Medicine, served as chair of the AATS writing committee. He appointed a group of experts that included adult cardiac surgeons and cardiologists to review the literature and provide recommendations. Each recommendation in the final document received at least 75 percent approval from the committee. The guidelines were last updated in 2015.

“We acknowledge that ischemic [mitral regurgitation] remains a challenging situation for the clinician and surgeon,” Kron said in a news release. “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.”

The authors noted guidelines from the American College of Cardiology/American Heart Association and European Society of Cardiology only briefly mention treating ischemic mitral regurgitation because of a lack of data. However, they noted that more data has become recently available, including two-year results of two randomized studies as well as meta-analyses and observational studies.

They defined ischemic mitral regurgitation as a disease of the left ventricle that affects patients with evidence of coronary artery disease and previous MI. Patients must have regional or global dysfunction or dilatation of the left ventricle.

The authors recommended using an integrative approach and specific imaging criteria to define the severity of mitral regurgitation. In addition, they wrote that percutaneous transcatheter mitral repair with the MitraClip (Abbott) could be used for degenerative mitral valve disease but not for ischemic mitral regurgitation.

They also mentioned that patients with severe ischemic mitral regurgitations have similar mortality rates whether they undergo mitral repair or replacement, while patients with moderate ischemic mitral regurgitation could be successfully treated with CABG in certain circumstances.

The guidelines suggested that mitral replacement could be an option for patients with severe ischemic mitral regurgitation who have dyskinesis, significant echocardiographic evidence of leaflet tethering or moderate to severe left ventricular remodeling. Meanwhile, they said that mitral repair could be considered for patients who do not have dyskinesis, significant leaflet tethering or severe left ventricular enlargement.

“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,” Kron said in a news release. “There is no doubt that the guidelines will continue to evolve as reports of longer-term follow-up emerge.”