Why is the primary focus on mitral valve (MV) repair rather than correcting both mitral regurgitation (MR) and aortic regurgitation (AR) in a patient with mitral valve prolapse, severe MR, normal left ventricular ejection fraction (LVEF) > 60%, and mild to moderate AR?

From the Guidelines

The primary focus on mitral valve repair rather than addressing both mitral and aortic regurgitation is due to the severity of the conditions, with severe mitral regurgitation (MR) taking precedence over mild to moderate aortic regurgitation, as indicated by the 2024 ACC/AHA clinical performance and quality measures for adults with valvular and structural heart disease 1. The patient's severe MR with mitral valve prolapse requires intervention to prevent heart failure, pulmonary hypertension, and atrial fibrillation, whereas mild to moderate aortic regurgitation can often be monitored without immediate surgical intervention. The preserved ejection fraction (>60%) indicates that the left ventricle is still functioning well despite the valvular issues. Surgical decision-making typically prioritizes addressing the most severe valve lesion first, especially when it's clearly symptomatic or has the potential to cause more immediate harm, as supported by the 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation 1. Additionally, mitral valve repair carries lower risks than combined valve procedures, and the minimally invasive approach further reduces surgical morbidity. The aortic regurgitation will likely continue to be monitored during follow-up visits, with intervention considered only if it progresses to severe or becomes symptomatic. This staged approach to valvular heart disease management balances the benefits of treating the most pressing condition against the risks of more extensive surgery, in line with the recommendations from the 2014 AHA/ACC guideline for the management of patients with valvular heart disease 1. Key considerations in this decision include the severity of the valve lesions, the patient's symptoms, and the left ventricular function, as outlined in the 2024 ACC/AHA clinical performance and quality measures for adults with valvular and structural heart disease 1. By prioritizing the repair of the mitral valve, the patient's risk of developing heart failure and other complications associated with severe MR is reduced, while also minimizing the risks associated with more extensive surgical procedures. The decision to focus on mitral valve repair is further supported by the fact that the patient's aortic regurgitation is mild to moderate, and intervention for this condition can be considered at a later time if it progresses or becomes symptomatic, as indicated by the 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation 1.

From the Research

Mitral Valve Repair Focus

The main focus on mitral valve repair rather than correction of both mitral regurgitation and aortic regurgitation can be attributed to several factors:

• The patient's primary condition is mitral valve prolapse with severe MR, which is the primary cause of concern and requires immediate attention 2.
• The patient has a normal ejection fraction (> 60%), which indicates that the left ventricular function is preserved, and mitral valve repair is a suitable option 3, 4.
• Mild to moderate aortic regurgitation may not be considered a significant concern at this point, and the focus is on repairing the mitral valve to alleviate the severe MR 2.

Rationale for Mitral Valve Repair

The rationale for mitral valve repair in this case can be supported by the following points:

• Mitral valve repair is generally preferred over replacement, especially in patients with preserved left ventricular function, as it can provide better long-term outcomes and reduce the risk of complications 3, 5.
• The study by 4 demonstrates that mitral valve repair can be effective in patients with heart failure with preserved ejection fraction (HFpEF) and atrial functional mitral regurgitation (AFMR), which may be relevant to this patient's condition.
• The fact that the patient undergoes minimally invasive mitral valve repair suggests that the surgical approach is focused on repairing the mitral valve, which is the primary cause of concern 4.

Aortic Regurgitation Consideration

The lack of comment on the aortic regurgitation from the cardiology or cardiac surgeon team may indicate that:

• The aortic regurgitation is not considered severe enough to require immediate attention 2.
• The focus is on repairing the mitral valve, and the aortic regurgitation may be addressed at a later time if necessary 2.
• There is limited evidence to suggest that correcting both mitral regurgitation and aortic regurgitation simultaneously would provide significant benefits in this patient's case 2, 3.