ABC | Volume 112, Nº5, May 2019

Updated Updated Geriatric Cardiology Guidelines of the Brazilian Society of Cardiology – 2019 Arq Bras Cardiol. 2019; 112(5):649-705 artery pressure are especially important. Identification of the cause and detailed evaluation of valvular apparatus impairment, leaflet morphology, and reflux mechanism are important for deciding whether the most adequate treatment is mitral valve replacement or plasty. 202,221,222 Transesophageal echocardiography (TEE) may be used when there are technical difficulties to acquiring an adequate echocardiography window. Cardiac catheters are indicated for diagnosis of CAD in patients referred for surgery and in cases where there are doubts regarding the severity of the lesion. 102,202,221,222 ET/ ergospirometry may be used to evaluate the reproduction of symptoms and changes in tolerance to exercise. They are less used with very elderly patients with physical limitations. 202,217,221,222 Magnetic resonance and computerized tomography are not routinely used in patients with mitral disease, but they may be indicated when the severity of MR or LV function have not been adequately evaluated by echocardiogram or when there are discrepancies. 221,222 6.2.2. Treatment Peculiarities Treatment of MR should consider its etiology and severity. AF, pulmonary hypertension, and symptoms are relevant factors in the decision making process. Elderly patients > age 75 have elevated surgical risks. Surgical management in this age range will aim to improve and maintain quality of life. Thus, the symptoms present are a determining factor for surgical indication. Patients with ventricular dysfunction who are asymptomatic should continue clinical treatment. 221 Therapeutic decisions for MR should be guided by presentation (acute or chronic), clinical hemodynamic profile, and severity of symptoms. Echocardiography parameters, such as LVEF, left ventricular end-systolic diameter (LVESD), and the presence of dyspnea are indicators for surgical therapy (See the following recommendations table). Mitral plasty is the preferred surgical treatment. Currently, mitral clips are an incipient and promising alternative. 221,223 Treatment of acute MR – In patients with acute, severe MR, immediate surgical treatment is recommended. Some patients with moderate MR may develop hemodynamic compensation due to LV dilation, thus making lower filling pressure and normalization of cardiac output possible. In cases of chordae tendineae rupture, mitral repair is preferable to mitral replacement, and surgery may be scheduled according to the patient’s clinical and hemodynamic status. 221,223,224 Medical treatment of acute MR must by implemented as a support therapy for the definitive surgical correction. 221 In the presence of severe manifestations, such as acute pulmonary edema or shock, vasoactive drugs, such as intravenous vasodilators, sodium nitroprusside, nitroglycerin, and vasopressin amines, in addition to an intra-aortic balloon for hemodynamic support, should be used up to the moment of the indicated surgical procedure. 223 Treatment of chronic MR – Patients with chronic, asymptomatic MR and normal LVEF are not indicated for medical treatment. There is no evidence that long-term treatment with vasodilators presents therapeutic benefits. 221 In symptomatic patients, treatment with ACEI, beta-blockers, such as carvedilol, and diuretics should be implemented. 224,225 Biventricular pacemakers in patients classified as “responders” show improvements in MR in reverse LV geometry. 226 Patients with symptomatic chronic primary MR should undergo surgical treatment, preferably plasty, regardless of LV function. Asymptomatic patients who have progressive dysfunction (LVEF < 0.60) and/or increased ventricular diameters (LVESD > 45 mm), should also be considered surgery. Indication for valve surgery in elderly patients > age 75 has not been consistently evaluated in clinical trials, it being necessary to prioritize the presence of symptoms as an indication for invasive intervention. In valve replacement surgery, bioprostheses are indicated in elderly patients owing to their lower rates of prosthetic dysfunction and to the inherent risks of anticoagulant therapy. 227,228 Percutaneous treatment of mitral regurgitation – Percutaneous treatment of MR has been performed, particularly in Europe. In Brazil, MitraClip® is the only commercially available device, and it is used only in select cases, owing to the high cost. The use of this device is indicated in patients whose primary chronic MR is degenerative in etiology and whose surgical risks are high or prohibitive. Furthermore, patients with chronic MR secondary to ventricular dilation who are refractory to optimized clinical treatment and cardiac resynchronization may eventually benefit from this procedure. In symptomatic patients with severe MR due to degeneration of a bioprosthesis or previously implanted valve rings and prohibitive surgical risks, percutaneous mitral replacement via the valve-in-valve procedure at a specialized center is an alternative. Percutaneous mitral replacement for symptomatic patients with severe native valve MR and prohibitive surgical risks is at an advanced phase of development and should be available in Brazil in the coming years. 229 Recommendations for MR surgery Recommendation Grade of recommendation Level of evidence Symptomatic patients with severe acute MR I C Symptomatic patients with severe chronic primary MR and normal left ventricular function I B Asymptomatic patients severe chronic primary MR and left ventricular function (EF 30-60% and/or end-systolic diameter ≥ 40 mm) I B Plasty is preferable to mitral replacement in severe chronic primary MR patients I B Plasty or mitral replacement is indicated in patients with severe chronic primary MR and patients undergoing concomitant heart surgery I B Mitral replacement is preferable to plasty in patients with chronic secondary MR of ischemic etiology I A Mitral plasty may be considered for chronic primary (non-rheumatic) MR, normal ventricular function, and new atrial fibrillation or pulmonary hypertension (resting PASP > 50 mmHg) IIa B 680