ACC Expert Consensus Decision Pathway for Mitral Regurgitation Management: 2020 Update

Mitral valve repair
Mitral valve repair in mitral valve regurgitation with coronary artery disease
The ACC published a focused update of the 2017 expert consensus decision pathway on the management of mitral regurgitation.

The American College of Cardiology (ACC) published a focused update of the 2017 expert consensus decision pathway on the management of mitral regurgitation in the Journal of the American College of Cardiology. In this update, an expert writing committee provides recommendations to guide the management of patients with mitral regurgitation, which should include clinical and echocardiographic assessment, establishment of mitral regurgitation etiology, identification of hemodynamic consequences, and of need for surgical or transcatheter intervention.

Recommendations for Transcatheter Repair

In the 2017 expert consensus decision pathway, it was recommended that transcatheter edge-to-edge repair be limited to prohibitive surgical-risk patients with primary mitral regurgitation. Data from randomized controlled trials published in 2018 support the use of transcatheter edge-to-edge repair in selected patients with heart failure and secondary mitral regurgitation. Based on these randomized controlled trial data, the Food and Drug Administration approved in 2019 the use of this intervention with a clip device in this patient population. 

In the 2017 document, the hemodynamic effects associated with mitral regurgitation were restricted to primary mitral regurgitation; the 2020 update recognizes that such effects should also be taken into account in secondary mitral regurgitation. The 2020 update recommends that a clinical algorithm — based on data from transcatheter edge-to-edge repair and severity of mitral regurgitation — for the referral of patients with chronic mitral regurgitation, also be used in patients with secondary regurgitation, and that the algorithm be modified to include rhythm control data.

Transcatheter mitral valve repair with an edge-to-edge clip device is now also used in carefully selected patients with secondary mitral regurgitation with persistent heart failure symptoms despite rigorous guideline-directed management and therapy.

Patients who have undergone mitral valve intervention, transcatheter or surgical, should be followed in the long term to assess the durability of mitral repair reduction, functional outcome, quality of life, and survival.

Hemodynamic Effects of Mitral Regurgitation

In secondary mitral regurgitation, mitral regurgitation is generally caused — not a result of — by reduced function and left ventricular dilation. In addition, secondary mitral regurgitation may, in some patients, be a marker of a diseased ventricle, and in others, may contribute to the progression of left ventricular remodeling and dysfunction, and therefore be associated with a worse prognosis. 

Clinical Algorithm for Referring Patients with Chronic Mitral Regurgitation Based on TTE Findings and Mitral Regurgitation Severity

The updated expert consensus decision pathway includes a roadmap to guide clinicians treating patients with mitral regurgitation, and help them determine whether to refer for valve treatment or further test their patients. With this referral algorithm, the patient initially receives a diagnosis of mitral regurgitation (mild/moderate or >moderate) based on transthoracic echocardiogram findings. The type of mitral regurgitation is then determined (primary, mixed, or secondary).  Primary mitral regurgitation is classified as symptomatic or asymptomatic, and mixed/secondary mitral regurgitations undergo diagnostic testing to determine the etiology and assess left ventricular function.

Management of Severe Mitral Regurgitation

In the 2017 expert consensus decision pathway on the management of mitral regurgitation, it is recommended that severe mitral regurgitation be solely treated with surgery. The 2020 update expands the treatment of severe mitral regurgitation (primary and secondary symptomatic) to transcatheter mitral valve therapy.

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“[This expert consensus decision pathway] can serve as a guide to patient assessment and individualized decision-making,” noted the report authors.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Bonow RO, O’Gara PT, Adams DH, et al. 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation [published online February 10, 2020]. J Am Coll Cardiol. doi:10.1016/j.jacc.2020.02.005