Finally, the new guidelines include recommendations for using transcatheter valves and the mitral clip to treat patients with secondary MR with LV dysfunction. This is not yet an approved indication from the Food and Drug Administration, pending the results of three ongoing trials, but in Europe, more than 70% of patients getting a mitral clip do so for secondary MR rather than primary mitral valve prolapse, Dr. Bonow said. The European guidelines came out 2 years ahead of the new AHA/ACC guidelines because writing was delayed until these devices were approved in the United States.
Secondary MR, or disease of the heart muscle, remains “problematic” because of a lack of outcomes data indicating that surgery leads to a better outcome than medical management in patients with LV dysfunction and because of questions raised by the Cardiothoracic Surgical Network about whether these valves should be repaired rather than replaced, he said.
What remains is a solid class 1 recommendation for guideline-directed medical therapy for heart failure including cardiac resynchronization therapy (CRT).
The surgical indications in secondary MR are class IIa for patients with severe MR undergoing coronary artery bypass grafting or aortic valve replacement and class IIb for those not undergoing such surgeries, but with severe MR and persistent symptoms, despite medical therapy, including CRT.
“There’s no data we’re going to improve survival ... but clearly some patients will have a dramatic improvement in symptoms,” Dr. Bonow said.
Dr. Bonow disclosed reviewing grant applications for the Gilead (Sciences) Scholars Program. Dr. Adams disclosed royalties as an inventor for Edwards Lifesciences and Medtronic, and serving as a Medtronic national coprimary investigator for the CoreValve Trial.