What is the initial management approach for patients with mitral valve regurgitation?

From the Guidelines

The initial management of mitral valve regurgitation should prioritize guideline-directed medical therapy (GDMT) and collaborative heart team management, with consideration of surgical or transcatheter interventions based on symptom severity, regurgitation degree, and left ventricular function, as recommended by the most recent guidelines 1.

Key Considerations

• For asymptomatic patients with mild to moderate regurgitation and preserved left ventricular function, watchful waiting with regular echocardiographic monitoring every 6-12 months is appropriate.
• Patients should receive endocarditis prophylaxis before dental or invasive procedures, typically with amoxicillin 2g orally one hour before the procedure (or clindamycin 600mg for penicillin-allergic patients).
• For symptomatic patients or those with severe regurgitation, medical therapy includes afterload reduction with ACE inhibitors like enalapril (starting at 2.5mg twice daily, titrating up to 10-20mg twice daily) or ARBs such as losartan (25-100mg daily).
• Diuretics like furosemide (20-80mg daily) help manage volume overload and pulmonary congestion.
• Beta-blockers such as metoprolol (12.5-200mg daily) may be added to control heart rate if atrial fibrillation develops.

Surgical and Transcatheter Interventions

• Surgical intervention (repair or replacement) should be considered when patients develop symptoms, left ventricular dysfunction (ejection fraction <60%), or left ventricular dilation (end-systolic dimension >40mm), as medical therapy alone is insufficient for progressive disease 1.
• Transcatheter edge-to-edge repair (TEER) may be considered as an alternative to surgical repair in patients with symptomatic severe primary mitral regurgitation and high or prohibitive surgical risk, or in patients with severe secondary mitral regurgitation who remain symptomatic despite optimal medical therapy 1.

Collaborative Heart Team Management

• All therapeutic decisions should be taken by a collaborative heart team, including cardiologists, cardiac surgeons, and other relevant specialists.
• The heart team should assess the patient's overall clinical condition, including symptom severity, regurgitation degree, left ventricular function, and other comorbidities, to determine the best course of treatment.

From the Research

Initial Management Approach for Mitral Valve Regurgitation

The initial management approach for patients with mitral valve regurgitation involves a combination of medical and surgical interventions.

• Medical management focuses on reducing cardiac workload, combating cardiac remodeling, and treating left ventricular failure 2.
• The use of ACE inhibitors and angiotensin receptor blockers (ACE-I/ARB) has been shown to improve clinical outcomes in patients with moderate-to-severe mitral regurgitation and preserved to mildly reduced left-ventricular ejection fraction 3, 4.
• ACE inhibitors and ARBs have been found to reduce the regurgitant fraction, regurgitant volume, and left ventricular size by a modest degree in chronic primary mitral regurgitation 4.

Timing of Intervention

• Early surgery in asymptomatic patients is considered the preferred approach, as waiting for symptoms or left ventricular dysfunction can lead to poor outcomes 5.
• The optimal timing of intervention requires a comprehensive 2-dimensional and Doppler echocardiogram to determine the cause of the mitral valve disease, the severity of the regurgitation, and the effect of the volume overload on the left ventricle 6.
• New objective markers of adverse outcome under medical management have been described, allowing selection of patients for performance of restorative surgery that reestablishes life expectancy 5.

Treatment Strategies

• Surgical management is reserved for severe cases of mitral regurgitation, and early mitral repair before the appearance of symptoms or overt LV dysfunction may restore life expectancy 5.
• Advances in both surgical and catheter-based therapies have resulted in recommendations for lower thresholds for operation and extension of interventional treatments to the older, sicker population of patients with mitral regurgitation 6.