This is an update to the 2017 American College of Cardiology (ACC) expert consensus decision pathway (ECDP) on the management of mitral regurgitation (MR). Recommendations are based on the 2014 American Heart Association/ACC Guideline for the Management of Patients With Valvular Heart Disease and its 2017 Focused Update. The following are key points to remember:

1. The ECDP continues to emphasize clinical assessment in terms of the identification of MR; the determination of the etiology and mechanism of MR (primary, secondary, or mixed; using the Carpentier classification); determination of MR severity; assessment in appropriate patients of the feasibility of surgical or transcatheter intervention; and indications for consideration for referral to a regional, comprehensive valve center.
2. The assessment of MR severity primarily relies on echo/Doppler, and should be done using an integrative approach that incorporates multiple parameters, including semi-quantitative measures (vena contracta width or area) and quantitative measures (effective regurgitant orifice area [EROA], regurgitant volume [RVol], and regurgitant fraction [RF]). However, because of the variety of factors that can affect quantitative measures, they should be used as part of an integrative approach to define MR severity, and not in isolation.
3. Associated findings also should be evaluated as part of the assessment of MR severity, including left atrial and left ventricular (LV) size, and pulmonary artery systolic pressure (PASP). Ancillary testing may include transesophageal echocardiography; cardiac magnetic resonance imaging; catheterization/angiography; and exercise echocardiography to screen for otherwise occult symptoms, worsened MR, elevation of PASP, or absence of normal LV or right ventricular contractile reserve.
4. Primary and secondary MR have important differences in terms of prognosis, evaluation, and management.
5. Differences in the assessment of MR severity in primary versus secondary MR in part relate to differences in orifice shape; the effect of blood pressure on MR; and the impact of LV size on the relationships between EROA, RVol, and RF.
6. The ECDP includes recommendations regarding referral of patients to a comprehensive valve center based on the etiology and severity of MR, the clinical context, symptoms, LV size and systolic function, and (in the setting of secondary MR or mixed primary and secondary MR) the response to guideline-directed management.
7. The principal treatment of primary MR is surgery. Surgeon experience has been recognized as an important determinant of successful mitral valve repair. Referral for repair to an experienced mitral surgeon at a heart valve center should be considered for patients with severe MR in whom other cardiac diseases require concomitant operative management, for patients in whom complex repair of primary MR is considered, or for patients with primary MR who wish to pursue a minimally invasive or robotic approach.
8. Transcatheter edge-to-edge clip mitral repair can be considered among patients with primary MR and severe symptoms who are poor surgical candidates.
9. Surgical correction of secondary MR may improve symptoms and quality of life, but has not been shown to improve survival. One randomized controlled trial demonstrated that transcatheter edge-to-edge clip repair of secondary MR improves both quality of life and survival among selected patients with heart failure (HF) and moderate to severe secondary MR who remain symptomatic despite optimal treatment with guideline-directed management of HF.
10. Surgical or transcatheter treatment for secondary MR should be undertaken only after appropriate medical and device therapies have been instituted and optimized as judged by the multidisciplinary team, with input from a cardiologist experienced in managing heart HF and MR. Transcatheter mitral valve repair systems (other than the edge-to-edge clip) and transcatheter mitral valve replacement devices currently are not approved for clinical use in the United States, but remain the subject of intense investigation.
11. Long-term follow-up of patients after surgical or transcatheter mitral valve intervention is essential for the assessment of durability of MR reduction, functional outcomes, and survival.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Mitral Regurgitation

Keywords: Angiography, Atrial Fibrillation, Blood Pressure, Blood Pressure Determination, Cardiac Catheterization, Cardiovascular Surgical Procedures, Diagnostic Imaging, Echocardiography, Transesophageal, Heart Valve Diseases, Heart Valve Prosthesis, Heart Defects, Congenital, Heart Failure, Magnetic Resonance Imaging, Mitral Valve, Mitral Valve Insufficiency, Patient Care Team, Pulmonary Artery, Quality of Life, Systole, Transcatheter Aortic Valve Replacement

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