The AHA Guidelines and Scientifi c Statements Handbook
(ejection fraction less than 0.30 and/or end-systolic
dimension greater than 55 mm) in whom MV repair
is highly likely. (Level of Evidence: C) ESC recom-
mendation, IIa (C) for those is whom durable repair
is likely but IIb (C) for those in whom successful
repair is unlikely
Class IIb
Mitral valve repair may be reasonable for patients
with chronic severe secondary MR* due to severe LV
dysfunction (ejection fraction less than 0.30) who
have persistent NYHA functional class III–IV symp-
toms despite optimal therapy for heart failure,
including biventricular pacing. (Level of Evidence: C)
No ESC recommendation
Class III
1 Mitral valve surgery is not indicated for asymp-
tomatic patients with MR and preserved LV func-
tion (ejection fraction greater than 0.60 and
end-systolic dimension less than 40 mm) in whom
signifi cant doubt about the feasibility of repair
exists. (Level of Evidence: C)
2 Isolated MV surgery is not indicated for patients
with mild or moderate MR. (Level of Evidence: C)
Ischemic mitral regurgitation
CABG alone is usually insuffi cient and leaves many
patients with signifi cant residual MR, and these
patients would benefi t from concomitant MV repair
at the time of the CABG. Mitral annuloplasty alone
with a downsized annuloplasty ring is often effective
at relieving MR. There were no specifi c ACC/AHA
class recommendations, but the ESC guidelines
provide the following recommendations:
1 ESC recommendation: Patients with severe MR,
LV ejection fraction >0.30 undergoing CABG, class
I (C).
2 ESC recommendation: Patients with moderate
MR undergoing CABG if repair is feasible, class IIa
(C).
3 ESC recommendation: Symptomatic patients
with severe MR, LV ejection fraction <0.30 and
option for revascularization, class IIa (C).
4 ESC recommendation: Patients with severe MR,
LV ejection fraction <0.30, no option for revascular-
ization, refractory to medical therapy, and low
comorbidity, class IIb (C).
Tricuspid valve disease
Management
Class I
Tricuspid valve repair is benefi cial for severe TR in
patients with MV disease requiring MV surgery. (Level
of Evidence: B) ESC recommendation, I (C) for severe
TR in patients undergoing left-sided valve surgeryClass IIa
1 Tricuspid valve replacement or annuloplasty is
reasonable for severe primary TR when symptom-
atic. (Level of Evidence: C) ESC recommendation, I
(C)
2 Tricuspid valve replacement is reasonable for
severe TR secondary to diseased/abnormal tricuspid
valve leafl ets not amenable to annuloplasty or repair.
(Level of Evidence: C) No ESC recommendation
3 ESC recommendation: Severe TR and symptoms,
after left-sided valve surgery, in the absence of left-
sided myocardial, valve, or RV dysfunction and
without severe pulmonary hypertension (systolic
pulmonary artery pressure >60 mm Hg), IIa (C).Class IIb
1 Tricuspid annuloplasty may be considered for less
than severe TR in patients undergoing MV surgery
when there is pulmonary hypertension or tricuspid
annular dilatation. (Level of Evidence: C) ESC rec-
ommendation, IIa (C), with defi nition of tricuspid
annular dilatation of >40 mm
2 ESC recommendation: Severe isolated TR with
mild or no symptoms and progressive dilation or
deterioration of RV function, IIb (C).Class III
1 Tricuspid valve replacement or annuloplasty is
not indicated in asymptomatic patients with TR
whose pulmonary artery systolic pressure is less than
60 mm Hg in the presence of a normal MV. (Level
of Evidence: C)
2 Tricuspid valve replacement or annuloplasty is
not indicated in patients with mild primary TR.
(Level of Evidence: C)Endocarditis
Indications for transthoracic echocardiography
Class I
1 Transthoracic echocardiography to detect valvu-
lar vegetations with or without positive blood cul-