Do we have to operate on moderate functional mitral regurgitation during aortic valve replacement for aortic stenosis?: Table 1:

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Do we have to operate on moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) for aortic stenosis (AS)?' Altogether 325 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The current evidence obtained from these papers revealed that the significant predictors of improvement outcome include lower preoperative mitral regurgitation and lower preoperative left ventricle fractional area change. We also know that persistent atrial fibrillation, enlarged left atrium, increased indexed left ventricular mass, pulmonary hypertension and preoperative peak aortic valve gradient <60 mmHg are predictors of deterioration. Generally, we observed a trend towards improvement or non-progression of FMR following AVR for AS. In the six papers that suggest conservative treatment of FMR, the degree of mitral regurgitation (MR) improved in 45-95%, remained unchanged in 19-38% and deteriorated in 1-14%. In the three papers favoring surgical treatment of MR, the degree of MR improved in 46-69%, stay unchanged in 34-53% and deteriorated in 10%. The current evidence suggests that moderate or less grade of FMR without predictors of deterioration should be treated conservatively and moderate-severe and severe FMR warrants additional surgical procedure. A clearly randomized study, especially in patients with moderate and moderate-severe FMR for AS, seems appropriate to further elucidate surgical strategy.

Change in Functional Moderate Mitral Regurgitation after Aortic Valve Replacement

“…Matsumura et al showed that 36% of AS patients with moderate MR would not benefit from AVR. Kowalówka et al showed that moderate MR remained unchanged in 19-38% and deteriorated in 1-14% of patients after AVR [3,4] . Actually, combined aortic and mitral valve replacement presented a high risk during the operation and affected the survival rate (in-hospital mortality, 15.5%; median survival rate, 7.3 years) [9] .…”

“…Surgical intervention must be carefully selected because double valve surgery is more associated with increased mortality [2] than isolated aortic valve replacement (AVR). Besides, additional mitral valve intervention during AVR had been long debated, especially for functional MR [1-4] . It was important to improve the degree of moderate MR after AVR.…”

“…It was important to improve the degree of moderate MR after AVR. Up to now, some studies with small patient cohort and short-term follow-up results had been reported on this topic [3,4] , but the results remained controversial. In addition, the cases in most of the published reports were patients with relatively old ages.…”

Functional Mitral Regurgitation After Aortic Valve Replacement for Aortic Insufficiency

“…It is well described that in patients with mild functional mitral regurgitation (FMR) due to aortic stenosis (AS)induced left ventricular pressure overload, aortic valve replacement (AVR) leads to significant reversal of pathologic ventricular remodeling and improvement or resolution of FMR. [1][2][3][4][5][6][7][8] Even though this effect is not as well documented in moderate FMR, previous literature and current guidelines 9 support more conservative management of lower-grade functional mitral regurgitation at the time of AVR and avoids unnecessary concomitant mitral valve intervention. It remains unclear whether a similar management strategy can be applied safely to aortic insufficiency (AI).…”

Prognosis of functional mitral regurgitation after aortic valve replacement for pure severe aortic stenosis

“…Four major systematic reviews pooling several observational studies have focused on the association of severe AS and MR in an attempt to identify the best surgical approach. One review found DVP to be preferable to an isolated aortic procedure, 7 while the three other reviews specified that no conclusive consensus could be reached based upon currently available literature, mainly because of methodological flaws 8–10 . Most pooled studies included an important proportion of patients with organic MR, an important confounding factor given the overwhelming evidence suggesting that organic MR does not improve after isolated AVR and should be considered an indication for DVP 11–15 .…”