What are the indications for surgery in patients with mitral valve regurgitation?

From the Guidelines

Surgery is indicated for mitral valve regurgitation in patients with severe symptomatic disease, asymptomatic patients with left ventricular dysfunction, and those with preserved ventricular function but with atrial fibrillation or pulmonary hypertension. The indications for surgery in mitral valve regurgitation can be broken down into several key points:

• Symptomatic patients with severe primary mitral regurgitation, irrespective of LV function, should undergo surgery 1.
• Asymptomatic patients with LV dysfunction, defined as LVEF <60% and/or LVESD >40 mm, should also undergo surgery 1.
• For secondary mitral regurgitation, surgery is recommended in patients who remain symptomatic despite guideline-directed medical therapy (GDMT) 1.
• The preference for mitral valve repair over replacement is clearly stated in both American and European guidelines, with repair being the preferred method when feasible 1.
• Transcatheter edge-to-edge repair may be considered as an alternative to MV surgery in patients with symptomatic severe primary mitral regurgitation and LV dysfunction who are at high/prohibitive risk for surgery 1. Some key considerations in the management of mitral valve regurgitation include:
• The timing of surgery is critical, as waiting until significant ventricular dysfunction develops can lead to poorer outcomes 1.
• The type of surgical intervention—repair versus replacement—depends on valve anatomy, etiology of regurgitation, and surgeon expertise 1.
• Mitral valve repair techniques include annuloplasty, leaflet resection, chordal transfer, or neochord implantation, while replacement options include mechanical or biological prostheses 1.

From the Research

Indications for Surgery in Mitral Valve Regurgitation

The decision to operate on patients with mitral valve regurgitation (MR) depends on various factors, including the presence of symptoms, left ventricular (LV) function, and the likelihood of successful mitral valve repair.

• Symptomatic patients with severe MR are clear candidates for surgical correction 2.
• Asymptomatic patients with severe MR who have developed LV dysfunction or dilation also warrant surgery 2.
• The presence of other clinical sequelae, such as atrial arrhythmias and pulmonary hypertension, can also influence the decision to operate 2.
• For asymptomatic patients without LV dysfunction or dilation, the decision to operate is less clear, with some evidence supporting earlier prophylactic surgery and other evidence supporting a "watch and wait" approach 2.

Role of Medical Therapy

Medical therapy can play a role in the management of MR, particularly in patients who do not meet criteria for surgery or are deemed high-risk for surgical therapy.

• Beta-blockers and renin-angiotensin-aldosterone system inhibitors have been shown to provide beneficial effects in patients with moderate to severe primary MR 3.
• Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can reduce MR, especially in asymptomatic patients 3.
• However, the precise role of medical therapy in MR management requires further study, including larger randomized controlled trials to confirm benefit and assess which subsets of patients are most likely to benefit 3.

Surgical Options

Surgical options for MR include mitral valve repair and replacement.

• Mitral valve repair is generally preferred for patients with primary MR, as it can cure the valve disease and improve LV function 4, 5.
• Mitral valve replacement may be necessary for patients with functional MR or those who are not candidates for repair 4, 5.
• The choice of surgical procedure depends on various factors, including the underlying cause of MR, LV function, and the presence of other cardiac conditions 5.

Trends in Mitral Valve Surgery

Recent studies have shown trends in mitral valve surgery, including an increasing proportion of patients undergoing transcatheter edge-to-edge mitral valve repair (M-TEER) 6.

• Patients undergoing M-TEER nowadays have lower surgical risk and are treated before they develop significant LV remodeling than before 6.
• The experience gained in the M-TEER procedure has brought a significant reduction in fluoroscopy time and hospitalization duration 6.
• Medical therapy has also changed over the last decade, with a higher use of angiotensin receptor blockers and lower use of angiotensin-converting enzyme inhibitors 6.