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Table 19. Diagnosis and Treatment of Patients With
Chronic Secondary MR
Recommendations COR LOE
Diagnosis
TTE is useful to establish the etiolog y of chronic secondary
MR (stages B-D) and the extent and location of wall
motion abnormalities and to assess global LV function,
severity of MR, and magnitude of PHTN.
I C
Noninvasive imaging (stress nuclear/positron emission
tomography, CMR, or stress echocardiography), cardiac
CT angiography, or cardiac catheterization, including
coronary arteriography, is useful to establish etiolog y
of chronic secondary MR (stages B-D) and/or to assess
myocardial viability, which in turn may influence
management of functional MR.
I C
Medical erapy
Patients with chronic secondary MR (stages B-D) and
HF with reduced LVEF should receive standard GDMT
therapy for HF, including angiotensin-converting enzyme
(ACE) inhibitors, angiotensin-receptor blockers (AR Bs),
beta blockers, and/or aldosterone antagonists as indicated.
I A
Cardiac resynchronization therapy (CRT) with
biventricular pacing is recommended for symptomatic
patients with chronic severe secondary MR (stages B-D)
who meet the indications for device therapy.
I A
Surgical Intervention
MV surgery is reasonable for patients with chronic severe
secondary MR (stages C and D) who are undergoing
coronary artery bypass gra (CABG) or AVR.
IIa C
It is reasonable to choose chordal-sparing MVR over
downsized annuloplasty repair if operation is considered
for severely symptomatic patients (NYHA class III to IV)
with chronic severe ischemic MR (stage D) and persistent
symptoms despite GDMT for HF.
(New recommendation for 2017)
IIa B-R
MV repair or replacement may be considered for severely
symptomatic patients (NYHA class III-IV) with chronic
severe secondary MR (stage D) who have persistent
symptoms despite optimal GDMT for HF.
IIb B
In patients with chronic, moderate, ischemic MR (stage B)
undergoing CABG, the usefulness of mitral valve repair is
uncertain. (Modified recommendation for 2017)
IIb B-R
