What is the management of severe Mitral Regurgitation (MR) with heart failure?

From the Guidelines

Management of severe mitral regurgitation (MR) with heart failure requires a comprehensive approach combining medical therapy and consideration for surgical intervention, with a focus on optimizing heart failure medications and evaluating for surgical intervention, particularly mitral valve repair or replacement, as this offers the best long-term outcomes for severe MR. The initial treatment should focus on optimizing heart failure medications including ACE inhibitors (e.g., lisinopril 10-40 mg daily), ARBs (e.g., valsartan 80-320 mg daily), beta-blockers (e.g., carvedilol 3.125-25 mg twice daily or metoprolol succinate 25-200 mg daily), and mineralocorticoid receptor antagonists (e.g., spironolactone 25-50 mg daily) 1. Diuretics like furosemide (20-80 mg daily or twice daily) should be used to manage fluid overload and symptoms. For patients with reduced ejection fraction, SGLT2 inhibitors (e.g., empagliflozin 10 mg daily or dapagliflozin 10 mg daily) have shown mortality benefits 1.

Some key points to consider in the management of severe MR with heart failure include:

• Optimizing heart failure medications to reduce symptoms and improve quality of life
• Evaluating for surgical intervention, particularly mitral valve repair or replacement, as this offers the best long-term outcomes for severe MR
• Considering transcatheter mitral valve procedures for those who are poor surgical candidates
• The timing of intervention is crucial - earlier intervention before significant left ventricular dysfunction develops yields better outcomes
• Regular echocardiographic monitoring (every 6-12 months) is essential to track disease progression

According to the most recent guidelines, transcatheter edge-to-edge repair (TEER) may be considered for patients with severe MR who are poor surgical candidates, have symptoms despite optimal medical therapy, and have favorable mitral valve anatomy 1. However, the decision to proceed with TEER or other transcatheter mitral valve interventions should be made on a case-by-case basis, taking into account the individual patient's risk profile, anatomy, and overall clinical condition.

In terms of specific treatment options, the guidelines recommend:

• Mitral valve surgery for patients with severe primary MR and symptoms, or those with severe secondary MR and symptoms despite optimal medical therapy
• TEER for patients with severe MR who are poor surgical candidates, have symptoms despite optimal medical therapy, and have favorable mitral valve anatomy
• Regular follow-up and monitoring to track disease progression and adjust treatment as needed.

From the Research

Management of Severe Mitral Regurgitation (MR) with Heart Failure

The management of severe Mitral Regurgitation (MR) with heart failure involves various treatment options, including:

• Medical therapy: Guideline-directed medical therapy remains the cornerstone of treatment for patients with heart failure and severe functional mitral regurgitation 2. Medical therapy, such as beta-blockers and renin-angiotensin-aldosterone system inhibitors, can provide beneficial effects, including lessening MR, preventing deterioration of left ventricular function, and improving survival in asymptomatic patients with moderate to severe primary MR 3.
• Transcatheter mitral valve therapies: Transcatheter mitral valve repair and replacement may play a crucial role in the management of severe secondary mitral regurgitation in patients with advanced heart failure 4. Transcatheter leaflet repair has been associated with significantly reduced 24-month mortality compared with medical therapy 5.
• Percutaneous repair of mitral valve regurgitation: Percutaneous mitral valve repair using MitraClip has been shown to result in reduction of MR and significant additional cardiac reverse remodelling compared to optimal medical therapy only 6.
• Surgery: Valvular interventions, such as surgery, may be considered in certain cases, although the optimal intervention remains controversial 5.
• Heart transplantation: Heart transplantation is considered the treatment of choice for advanced heart failure, but there is an unmet need due to the limited supply of donor hearts and the low eligibility of highly symptomatic patients 4.

Treatment Goals

The goals of treatment for severe MR with heart failure include:

• Hemodynamic stabilization
• Symptomatic relief
• Normalization of pulmonary arterial pressures
• Reduction in hospitalizations for acute heart failure
• Achieving traditional secondary endpoints, such as bridge to heart transplantation, bridge to HTx candidacy, and bridge to recovery 4.

Comparison of Treatment Options

Comparing treatment options, studies have shown that:

• Transcatheter leaflet repair is associated with significantly reduced 24-month mortality compared with medical therapy 5
• Valvular interventions are associated with lower rates of recurrent moderate-severe MR, but non-significant improvements in clinical outcomes 5
• Percutaneous mitral valve repair results in significant additional cardiac reverse remodelling compared to pharmacologically-only managed patients 6