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cardio.mitral-regurgitation.primary-chronic.v1

Chronic primary (degenerative) mitral regurgitation

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Chronic primary (degenerative) MR — intervention-timing engine keyed to ACC/AHA stage; surgical repair strongly preferred over replacement. NO disease-modifying pharmacotherapy (encoded explicitly as data). Sibling-differentiated from secondary/functional MR (opposite paradigm — GDMT-first, COAPT-class TEER) and acute severe MR (emergency). Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (2 regimen axes + workups + calculators + panels), test_files, evidence object, chronic phases all present. INTEGRATED (not PRODUCTION): procedure entries (surgical repair/replacement, TEER, maze, watchful-waiting) marked non_pharm; symptom-bridge/AF/anticoagulation RxCUIs reused from RxNav-validated canonical cardio profiles. 9 trigger/special-pop branches: Class I symptomatic, Class I LV, AF, pulmonary HTN, arrhythmic-MVP SCD, elderly/high-risk TEER, pregnancy, CKD, endocarditis-related. DEPTH-PASS-2 2026-05-18 (shard-07-cardio-chronic, chronic-valvular deepen): (1) co-located _design-brief.md + _research-bundle.md per §5.5 items 1+2 (23 distinct verified PMIDs incl. Enriquez-Sarano NEJM 2005 quantitation 15745978 / Ling flail 8875918 / Suri MIDA JAMA 23942679 / Lazam repair-vs-replace 27899396 / Kang early-surgery 19188506+24694528 / Rosenhek+Zilberszac watchful-waiting 16651470+30031699 / Barbieri PH 20829213 / Rusinaru LA 21737598 / Grigioni AF 30678755 / Grigioni 2008 19356418 / Avierinos ageing+sex 23853072+38751052 / EVEREST II 22423604+23665364+26718672 / Basso AMVP 26160859 / Dejgaard MAD 30261961 / EHRA 35951656 / MIDA-Q 36573420 / Etchells canon 9032164 / COAPT secondary-contrast 30280640; named trials + effect sizes + 95% CI + time-to-event; retrieval 2026-05-18; Consensus→WebSearch fallback logged); design_brief repointed to co-located ._design-brief.md. (2) cardio.mitral-regurgitation.primary-chronic.v1 differentials+ros+finding-lrs seed files created (10 differentials w/ cohort-anchored priors — apical-systolic-murmur/volume-overload partition incl. primary fibroelastic-vs-Barlow / secondary-route-out / MVP-without-MR / MR-mimics VSD-TR-HOCM-AS / acute-MR-route-out + MR severity strata MECE; 12 ROS; 35 LR rows = 30 LR+ AND 30 discriminating LR− (≥15 each floor met; 5 argues-against rows carry LR+<1 as negative discriminators); 3 conditional-dependency rules incl. EROA-method|PISA-vs-volumetric and severity|loading-conditions and nested-severity-bands; T_test EROA<0.20+normal-LV/LA excludes + primary-vs-functional mechanism gate / T_treat severity-staged Class I/IIa thresholds in header). (3) 2 regimen axes (primary_mr_severity_symptom_lv_staged severity/symptom/LV ladder + primary_mr_phenotype_intervention_matrix repair-vs-replace-vs-TEER × phenotype gating as DATA) encoding "no medical therapy alters primary-MR natural history" + intervention HR+95%CI+horizon enrichment. (4) RxCUIs aligned to canonical DrugEffectProfile profiles (furosemide 4603, torsemide 38413, metoprolol 221124 PIN, apixaban 1364430, warfarin 11289 — fixed from stale 855332/855296 to the canonical registry CUIs matching the cardio.aortic_stenosis.v1 exemplar); non-pharm interventions flagged non_pharm:true; no hand-authored CUIs; 96-fail RxNav registry baseline OUT OF SCOPE per prompt. (5) evidence.pmids 14→26 (stale cross-domain HF/AF trial PMIDs DAPA-HF 31535829 / EMPEROR-Reduced 32865377 / PARADIGM-HF 25176015 / RALES 10471456 / EAST-AFNET-4 32673028 / 2023-ESC-HF 37622666 / 2022-HF 35379504 and wrong EVEREST-II 21463154 / MITRA-FR 30145927 replaced with the verified distinct primary-MR set; HF/AF engines now referenced via cross-dossier routing not imported evidence); guideline content refreshed to 2020 ACC/AHA + 2021/2025 ESC/EACTS (EROA/RVol/RF severe thresholds, early surgery for asymptomatic severe primary MR with repair >95% & low risk at a Primary Valve Center, TEER prohibitive-risk Class IIb bounded to PRIMARY MR vs COAPT secondary, watchful-waiting triggers, 2025 ESC LVESDi). Status preserved INTEGRATED per prompt. DEPTH-PASS-3 2026-05-26 (lane-E): +NMA/meta (Iqbal anterior/bi-leaflet vs posterior MV repair meta Curr Probl Cardiol 2022 PMID 35970298 no long-term difference RR ~1.00; Luo+Yuan RHD MV repair-vs-replace review PMID 38718933; Lazam Circ 2016 PMID 27899396 retained as canonical 20-y repair 46% vs replace 23% anchor; CLASP IID PMID 36121247/37962288 PASCAL vs MitraClip prohibitive-risk DMR noninferior) +USPSTF (explicit "primary MR is NOT a USPSTF screening topic" flag; AF-screening grade I + tobacco-A + statin-B + ASA-C/D adjacent hooks documented) +Cochrane (CD003331 ACEi-HF + CD009541 MV surgery techniques CD-IDs listed as W2-cache stubs, matched PMIDs deferred for live verification — not fabricated) +ICER (Baron COAPT Circulation 2019 PMID 31564137 $55,600/QALY + Baron commentary US Cardiol 2020 PMID 39720449 — explicitly flagged SECONDARY-MR contrast NOT applicable to primary; direct primary-MR repair CE is meta-evidence gap awaiting REPAIR-MR NCT04198363) +Pauker-Kassirer thresholds explicit (T_test 10%/T_treat 20% asymptomatic severe early-surgery gate; symptomatic = trivially-treat; repair-vs-replace 70%/90% feasibility cutoffs; TEER Class IIb prohibitive-risk gate) anchored by PMID 7366635 (NEJM 1980); MITRA-FR PMID 30145927 added as sibling-contrast anchor for COAPT-vs-MITRA-FR meta-context; side-car at cardio.mitral-regurgitation.primary-chronic.v1._depth-pass-3.md. Zero schema churn; all 8 new PMIDs live-verified via PubMed MCP 2026-05-26. evidence.pmids 26→34.

Entry points (6)

  • symptom
    Apical holosystolic murmur radiating to axilla
    apical_holosystolic_murmur
  • imaging
    Echo: severe primary MR (EROA ≥0.40 cm², RegVol ≥60 mL, RF ≥50%)
    echo_severe_primary_mr
  • imaging
    Echo: MV prolapse / flail leaflet
    mvp_flail
  • symptom
    Exertional dyspnea / reduced exercise tolerance
    exertional_dyspnea
  • lab_abnormality
    New atrial fibrillation
    new_af
  • problem_list
    Known primary MR — surveillance visit
    known_primary_mr

Required inputs (13)

  • agerequired
    demographic • used at RISK_STRATIFICATION
    Surgical-risk + repair-durability + TEER candidacy
  • mr_mechanismrequired
    imaging • used at FRAME
    Primary (leaflet) vs secondary (annular/ventricular) determines the entire pathway
  • mr_severityrequired
    imaging • used at INITIAL_WORKUP
    EROA/RegVol/RF/vena contracta → ACC/AHA stage
  • lvefrequired
    imaging • used at RISK_STRATIFICATION
    LVEF 30–60% in severe primary MR = Class I surgery trigger
  • lvesdrequired
    imaging • used at RISK_STRATIFICATION
    LV end-systolic diameter ≥40 mm in severe primary MR = Class I surgery trigger
  • pasp
    imaging • used at RISK_STRATIFICATION
    PASP >50 mmHg → Class IIa intervention in asymptomatic severe
  • la_volume
    imaging • used at RISK_STRATIFICATION
    LA enlargement supports chronicity + AF risk
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    Symptomatic severe (stage D) = Class I surgery if LVEF >30
  • atrial_fibrillation
    history • used at CONTEXT
    New AF = Class IIa intervention trigger + AC + concomitant maze
  • arrhythmic_mvp_features
    history • used at CONTEXT
    Bileaflet MVP + mitral annular disjunction → SCD risk workup
  • bnp
    lab • used at RISK_STRATIFICATION
    Rising BNP supports earlier intervention in asymptomatic severe
  • creatininerequired
    lab • used at TREATMENT
    Pre-procedure contrast risk + AC dosing
  • surgical_risk
    history • used at RISK_STRATIFICATION
    STS/EuroSCORE → surgery vs TEER vs surveillance

12-phase flow (12)

  1. 1FRAME
    Confirm primary (leaflet) mechanism; if functional → cardio.mitral-regurgitation.secondary-chronic.v1; if acute severe → cardio.cardiogenic-shock.acute-mitral-regurgitation.v1
    inputs: mr_mechanism
    advance: primary chronic mechanism confirmed
  2. 2ENTRY
    Murmur / MVP / dyspnea / new AF / incidental severe MR
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Symptoms, AF, comorbidities, arrhythmic-MVP features, surgical-risk factors
    inputs: atrial_fibrillation, arrhythmic_mvp_features
    advance: context complete
  4. 4RED_FLAGS
    Flail with acute decompensation; syncope/malignant arrhythmia in arrhythmic MVP
    inputs: nyha_class
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to acute pathway
  5. 5INITIAL_WORKUP
    TTE: severity (EROA/RegVol/RF/VC), LVEF, LVESD, LA vol, PASP; ECG
    inputs: mr_severity
    actions: panel.cardiac
    advance: severity + LV metrics quantified
  6. 6BRANCHING_WORKUP
    TEE for repair candidacy; exercise echo if symptom/severity discordant; CMR when echo discordant; Holter/CMR for arrhythmic MVP; cath if pre-op CAD risk
    inputs: mr_mechanism
    actions: preop_cardiac, afib_new_onset
    advance: repair candidacy + discordance resolved
  7. 7DIFFERENTIAL
    Primary vs secondary MR vs MVP without significant MR vs mixed valve disease
    inputs: mr_mechanism, mr_severity
    advance: primary severe MR confirmed/staged
  8. 8RISK_STRATIFICATION
    ACC/AHA stage (C1/C2/D); LVEF/LVESD thresholds; PASP; AF; BNP; STS/EuroSCORE
    inputs: lvef, lvesd, pasp, nyha_class, bnp, surgical_risk
    advance: stage + intervention class assigned
  9. 9TREATMENT
    Intervention timing: surgery (repair preferred) by Class I/IIa triggers; TEER for symptomatic prohibitive-risk + favorable anatomy; symptom-directed medical bridge only
    inputs: creatinine
    advance: intervention decision documented or surveillance plan set
  10. 10DISPOSITION
    Refer to primary MV reference center; surveillance interval by stage
    inputs: nyha_class
    actions: preop_cardiac
    advance: referral or surveillance plan set
  11. 11MONITORING
    Serial TTE by severity (severe asymptomatic q6–12 mo; moderate q1–2 yr); symptom + AF surveillance
    inputs: mr_severity
    actions: panel.cardiac
    advance: surveillance cadence documented
  12. 12FOLLOWUP
    Post-repair surveillance; route to HFrEF engine if LV dysfunction (stage C2) develops
    inputs: lvef
    advance: follow-up + escalation triggers documented