What are the proper steps for a patient with newly diagnosed moderate to severe eccentric mitral valve regurgitation (MR) found on echocardiogram (echo), with a previous normal echo in 2023?

From the Guidelines

The patient with newly diagnosed moderate to severe eccentric mitral valve regurgitation (MR) should undergo prompt referral to a multidisciplinary team (MDT) for comprehensive evaluation and shared decision-making, as recommended by the 2020 ACC expert consensus decision pathway on the management of mitral regurgitation 1. The MDT should include experienced clinicians, such as cardiologists and cardiac surgeons, to discuss the patient's treatment options and develop a personalized management plan.

• The patient's evaluation should include a detailed history, physical examination, and additional imaging such as transesophageal echocardiography (TEE) to better characterize the valve pathology.
• The MDT should recognize the prognostic, evaluative, and management differences between primary and secondary MR, as outlined in the 2020 ACC expert consensus decision pathway 1.
• The patient should be considered for surgical intervention, such as mitral valve repair, if they develop symptoms, left ventricular ejection fraction drops below 60%, left ventricular end-systolic dimension exceeds 40 mm, or if pulmonary hypertension develops.
• The use of transcatheter mitral valve repair (TMVr) with an edge-to-edge clip device may be considered for patients with severe MR who are poor operative candidates or have persistent heart failure symptoms despite optimal medical therapy, as recommended by the 2020 ACC expert consensus decision pathway 1.
• Long-term follow-up of the patient after surgical or transcatheter MV intervention is essential for assessment of durability of MR reduction, functional outcome, quality of life, and survival, as emphasized in the 2020 ACC expert consensus decision pathway 1.

From the Research

Diagnosis and Assessment

• The patient has been diagnosed with moderate to severe eccentric mitral valve regurgitation (MR) on echocardiogram (echo), with a previous normal echo in 2023 2.
• Echocardiography is essential to assess MR etiology and severity, as well as the remodeling of cardiac chambers and longitudinal chamber changes to determine optimal therapies 2.
• The patient's previous normal echo in 2023 suggests that the MR may be a new development, and further evaluation is needed to determine the cause and severity of the condition.

Treatment Options

• Surgery is recommended for severe primary MR if persistent symptoms are present or if left ventricle dysfunction is present with an EF <60% or a left ventricle end-systolic diameter ≥40 mm 2.
• For secondary MR, therapy of heart failure with vasodilators and diuretics improves forward cardiac output 2.
• Coronary artery bypass grafts (CABG) or percutaneous coronary intervention (PCI) should be considered for severe MR due to ischemia 2.
• Angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, may be effective in reducing the severity of chronic moderate MR in asymptomatic patients with normal left ventricular function 3, 4.

Management and Follow-up

• Patients with moderate to severe MR should be closely monitored for signs of heart failure, such as shortness of breath, fatigue, and swelling in the legs and feet 5.
• Regular follow-up echocardiograms should be performed to assess the severity of the MR and the effectiveness of treatment 2, 4.
• The patient's blood pressure should be closely monitored, as ACE inhibitors may be more effective in reducing MR severity in patients with systemic hypertension 4.