From the Guidelines
Severe mitral regurgitation can lead to a wide pulse pressure due to the significant backward flow of blood from the left ventricle to the left atrium, resulting in volume overload and potential heart failure. The effects of severe mitral regurgitation include fatigue, shortness of breath, pulmonary edema, atrial fibrillation, and eventually right heart failure if left untreated. Management depends on symptom severity, ventricular function, and whether the condition is acute or chronic.
Key Considerations
- For symptomatic patients or those with reduced left ventricular function, surgical intervention is the definitive treatment, typically involving mitral valve repair (preferred) or replacement, as recommended by the American and European guidelines 1.
- Medical therapy is primarily used to manage symptoms and includes diuretics like furosemide to reduce fluid overload, ACE inhibitors such as enalapril to reduce afterload, and beta-blockers like metoprolol to control heart rate.
- For patients with atrial fibrillation, anticoagulation with warfarin or direct oral anticoagulants is necessary to prevent thromboembolism.
- Regular echocardiographic monitoring is essential for asymptomatic patients with preserved ventricular function, with intervention recommended when the ejection fraction falls below 60% or the left ventricular end-systolic diameter exceeds 40mm, as stated in the guidelines 1.
- The preference for MV repair over MV replacement is clearly stated in both guidelines, and transcatheter edge-to-edge repair (TEER) may be considered as an alternative to MV surgery only in patients with symptomatic severe PMR and LV dysfunction and considered to be at high/prohibitive risk for surgery by the heart team 1.
Management Approach
- The management approach should prioritize symptom severity, ventricular function, and the presence of comorbidities, with a focus on improving quality of life and reducing morbidity and mortality.
- A heart team approach is recommended for therapeutic decisions, taking into account the patient's overall clinical profile and the potential benefits and risks of each treatment option 1.
- The timing of intervention is critical, as waiting until symptoms are severe or ventricular dysfunction is established can result in irreversible myocardial damage and poorer outcomes.
From the Research
Effects of Severe Mitral Regurgitation
- Severe mitral regurgitation can lead to various clinical presentations, including heart failure with preserved left ventricular ejection fraction 2
- The condition can be caused by different mechanisms, such as left ventricular dyssynchrony, mitral annular dilatation, and coronary artery vasospasm 2
- Severe mitral regurgitation can result in a wide pulse pressure, although the exact relationship between the two is not explicitly stated in the provided studies
Management of Severe Mitral Regurgitation
- Mitral valve repair is considered the treatment of choice for patients with severe primary nonrheumatic mitral regurgitation 3
- The optimal surgical approach for functional mitral regurgitation remains controversial, but current guidelines suggest tailoring the approach to the individual patient 4
- Mitral valve re-repair is a valid clinical consideration in cases of valve repair failure, and techniques for re-repair have been developed 5
- Treatment for paroxysmal severe mitral regurgitation varies depending on the underlying cause, and may include cardiac resynchronization therapy, surgical valve replacement, or medical therapy 2
Surgical Outcomes
- Studies have shown that mitral valve repair can lead to superior outcomes compared to mitral valve replacement, with higher survival rates and improved quality of life 3, 4
- The choice of surgical approach depends on various factors, including the etiology of the mitral regurgitation, patient age, left ventricular function, and underlying heart rhythm 4