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2014 ACC/AHA valve guidelines: earlier intervention for chronic mitral regurgitation
  1. Rick A Nishimura1,
  2. Catherine Otto2
  1. 1Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
  2. 2Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
  1. Correspondence to Professor Catherine Otto, Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA; cmotto{at}u.washington.edu

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In the new 2014 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease, there have been a number of changes in the recommendations for diagnosis and management of mitral regurgitation (MR) compared with the prior version of 2006.1 As outlined in a previous editorial,2 the process of guideline writing was transformed in these newly released guidelines, so each class recommendation now is based upon published data summarised in large online evidence tables and then written in a modular format to allow quick and easy access at the point of care. This modular format will also allow for rapid updates as new trials emerge.

Primary MR disease stages

As with aortic stenosis, the concept of disease stages can be applied to patients with chronic primary MR to better aid the clinician in timing of operation (table 1). Stages A and B include patients at risk and asymptomatic patients with less than severe valve regurgitation. Stage C encompasses patients who meet criteria for ‘severe MR’ but remain asymptomatic. The new definition of ‘severe’ MR is based on integration of multiple parameters, including valve anatomy, regurgitant severity, LV size and systolic function and other consequences of chronic volume overload, such as pulmonary hypertension and atrial fibrillation. An effective orifice area of 0.4 cm2 or greater was defined as severe MR because natural history studies have demonstrated poor clinical outcomes in patients with this degree of valve regurgitation.

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Table 1

Stages of chronic primary MR

Asymptomatic patients with severe MR are divided into two groups based on LV systolic function: stage C-1 indicates normal LV systolic function, whereas patients in stage C-2 have evidence of early LV …

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