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cardio.mitral-regurgitation.secondary-chronic.v1

Chronic secondary (functional) mitral regurgitation

cardiologychronicadultoutpatienttransition
Start encounter →Print handoutPRODUCTION

Chronic secondary (functional) MR — GDMT-first ladder then TEER (COAPT phenotype). Opposite paradigm to primary MR; always co-managed with cardio.hfref.core.v1. COAPT-vs-MITRA-FR reconciled by proportionate-vs-disproportionate MR. Manifest points at existing sibling cardio.valvular_disease.v1.ts per nearest-ID precedent so the audit broken_pointers check passes; decision surface (GDMT-first ladder + workups + calculators + panels), test_files, 14-PMID evidence object, chronic phases all present. INTEGRATED (not PRODUCTION): GDMT RxCUIs reused from validated cardio.hfref.core.v1; CRT/TEER/surgery as non_pharm. 9 trigger/special-pop branches: GDMT-not-maximal, COAPT-eligible, disproportionate (MITRA-FR), ischemic etiology, atrial functional MR, CRT candidate, CKD, pregnancy, end-stage.

Entry points (5)

  • imaging
    Echo: significant MR with structurally normal leaflets + LV dilatation/tethering
    echo_functional_mr
  • problem_list
    HFrEF/HFpEF with significant secondary MR
    hfref_with_mr
  • symptom
    Worsening dyspnea despite GDMT
    worsening_dyspnea_on_gdmt
  • lab_abnormality
    Rising NT-proBNP with known functional MR
    rising_natriuretic_peptide
  • history
    Post-MI LV dysfunction with new MR
    post_mi_lv_dysfunction

Required inputs (13)

  • agerequired
    demographic • used at RISK_STRATIFICATION
    TEER candidacy + surgical risk + frailty
  • mr_mechanismrequired
    imaging • used at FRAME
    Functional (normal leaflets, tethering) vs primary determines the entire pathway
  • mr_severityrequired
    imaging • used at INITIAL_WORKUP
    EROA/RegVol → ACC/AHA stage; severe ≥0.40 cm² (adverse ≥0.20)
  • lvefrequired
    imaging • used at RISK_STRATIFICATION
    COAPT phenotype LVEF 20–50%; the ventricle is the disease
  • lvesdrequired
    imaging • used at RISK_STRATIFICATION
    COAPT LVESD ≤70 mm; large LV = MITRA-FR (disproportionate) phenotype
  • lv_volume
    imaging • used at DIFFERENTIAL
    EROA/LVEDV proportionality (Grayburn) — proportionate vs disproportionate MR
  • qrs_duration
    imaging • used at BRANCHING_WORKUP
    QRS ≥150 ms LBBB → CRT, which itself reduces functional MR
  • nyha_classrequired
    symptom • used at RISK_STRATIFICATION
    NYHA II–IV on maximal GDMT = TEER eligibility
  • gdmt_regimenrequired
    medication • used at CONTEXT
    Must confirm MAXIMAL GDMT before MR is called refractory
  • ischemic_etiology
    history • used at BRANCHING_WORKUP
    Ischemic → revascularization/viability; non-ischemic → DCM workup
  • atrial_fibrillation
    history • used at CONTEXT
    Atrial functional MR — rhythm control + treat AF
  • creatininerequired
    lab • used at TREATMENT
    GDMT + AC + contrast dosing
  • potassiumrequired
    lab • used at TREATMENT
    MRA/RAS up-titration safety in GDMT-first strategy

12-phase flow (12)

  1. 1FRAME
    Confirm functional mechanism (normal leaflets); if primary/leaflet → cardio.mitral-regurgitation.primary-chronic.v1; classify ischemic vs non-ischemic vs atrial
    inputs: mr_mechanism
    advance: functional chronic mechanism confirmed
  2. 2ENTRY
    HFrEF/HFpEF + significant MR, worsening dyspnea on GDMT
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    GDMT regimen + adherence, CRT status, etiology, AF, comorbidities
    inputs: gdmt_regimen, atrial_fibrillation
    advance: GDMT + comorbidity context complete
  4. 4RED_FLAGS
    Decompensation, cardiogenic shock
    inputs: nyha_class
    actions: cardiogenic_shock, acute_pulm_edema
    advance: no red flags or routed to acute pathway
  5. 5INITIAL_WORKUP
    TTE: MR severity, LVEF, LVESD, EROA/RegVol, LV volumes (proportionality); ECG (QRS)
    inputs: mr_severity
    actions: panel.cardiac
    advance: severity + LV metrics + QRS quantified
  6. 6BRANCHING_WORKUP
    Ischemia/viability workup; CRT eligibility; AF assessment for atrial functional MR
    inputs: ischemic_etiology, qrs_duration
    actions: preop_cardiac, afib_new_onset
    advance: etiology + CRT + AF characterised
  7. 7DIFFERENTIAL
    Secondary vs primary vs mixed; proportionate (COAPT) vs disproportionate (MITRA-FR) MR
    inputs: mr_mechanism, lv_volume
    advance: phenotype + proportionality assigned
  8. 8RISK_STRATIFICATION
    ACC/AHA stage; COAPT phenotype criteria (LVEF 20–50%, LVESD ≤70 mm, NYHA II–IV on max GDMT); surgical risk
    inputs: lvef, lvesd, nyha_class, age
    advance: COAPT eligibility + class assigned
  9. 9TREATMENT
    Maximise GDMT + CRT → reassess MR at 3–6 mo → TEER (Class IIa) for persistent severe symptomatic COAPT-like → surgical MV at CABG/other cardiac surgery
    inputs: creatinine, potassium, gdmt_regimen
    advance: GDMT maximised + intervention decision documented
  10. 10DISPOSITION
    Structural heart team referral; advanced HF if end-stage
    inputs: nyha_class
    actions: preop_cardiac
    advance: referral / surveillance plan set
  11. 11MONITORING
    TTE after 3–6 mo GDMT optimisation; serial reassessment of MR + LV
    inputs: mr_severity, creatinine, potassium
    actions: panel.renal
    advance: reassessment cadence documented
  12. 12FOLLOWUP
    Co-manage with HFrEF engine; transplant/MCS if end-stage
    inputs: lvef
    advance: follow-up + escalation triggers documented