What is the recommended treatment for severe mitral regurgitation (MR) due to mitral valve prolapse, transcatheter edge-to-edge repair (TEER) or surgical repair?

Management of Severe Mitral Regurgitation Due to Mitral Valve Prolapse: Surgical Repair vs. TEER

For patients with severe mitral regurgitation due to mitral valve prolapse, surgical mitral valve repair is strongly recommended as the first-line treatment over transcatheter edge-to-edge repair (TEER). 1

Primary Mitral Regurgitation Due to Mitral Valve Prolapse

Surgical Mitral Valve Repair: First-Line Therapy

• Both American and European guidelines provide a Class I recommendation (Level of Evidence: B) for surgical mitral valve repair in:

  • Symptomatic patients with severe primary MR and LVEF >30% 1
  • Asymptomatic patients with LV dysfunction (LVEF ≤60% and/or LVESD ≥40 mm) 1

• Mitral valve repair is strongly preferred over mitral valve replacement when:

  • The pathology is limited to the posterior leaflet (highest success rates) 1
  • A successful and durable repair can be accomplished for anterior or bileaflet involvement 1

• Benefits of surgical repair over replacement:

  • Improved very long-term survival (41% vs 31% at 15 years) 2
  • Better preservation of left ventricular function
  • Lower risk of endocarditis
  • No need for long-term anticoagulation

When to Consider TEER

TEER should be considered only in specific circumstances:

• Patients with severe symptomatic primary MR (NYHA class III-IV) 1
• High or prohibitive surgical risk 1
• Favorable mitral valve anatomy for the procedure 1
• Life expectancy of at least 1 year 1

The American guidelines give TEER a Class IIa recommendation in high-risk patients, while European guidelines give it a weaker Class IIb recommendation 1, reflecting less confidence in this approach for primary MR.

Comparative Outcomes: Surgery vs. TEER

Durability

• Surgical repair has superior durability compared to TEER:
  • Lower rates of recurrent moderate or severe MR at discharge (5.4% vs 43.1%) 3
  • Lower rates of recurrent MR at 1-year follow-up (33.3% vs 66.7%) 3
  • Higher freedom from mitral reintervention at 1 year (100% vs 87.5%) 3

Recovery Time

• TEER offers shorter hospital stays (median 2 days vs 7 days for surgery) 3
• However, this short-term benefit must be weighed against the significantly higher risk of residual or recurrent MR

Risk Stratification for Surgical Decision-Making

Factors Favoring Earlier Surgical Intervention

• New-onset atrial fibrillation (Class IIa recommendation) 1
• Pulmonary artery systolic pressure >50 mmHg at rest (Class IIa) 1
• Left atrial dilatation (LAVi ≥60 mL/m² or LAD ≥55 mm) (Class IIa) 1
• High likelihood of durable repair (>95%) with expected mortality <1% 1

Surgical Expertise Considerations

• Outcomes of mitral valve repair are highly dependent on surgeon experience and center volume 1
• Referral to a Heart Valve Center of Excellence is recommended when complex repair is anticipated 1
• Posterior leaflet repair has higher success rates (11% reoperation rate at 15 years) compared to anterior leaflet repair (28% reoperation rate at 15 years) 2

Follow-Up Recommendations

• Asymptomatic severe MR: echocardiographic evaluation every 6-12 months 1
• Monitor for:
  • Development of symptoms
  • LV dysfunction (LVEF ≤60%)
  • LV dilation (LVESD ≥40 mm)
  • Pulmonary hypertension
  • New-onset atrial fibrillation

Common Pitfalls to Avoid

1. Delaying surgery until symptoms develop - This may lead to irreversible LV dysfunction
2. Underestimating the importance of surgical expertise - Repair success rates vary significantly between centers
3. Choosing TEER based solely on shorter recovery time - This ignores the significantly higher risk of residual MR and need for reintervention
4. Failing to recognize the difference between primary and secondary MR - Treatment recommendations differ substantially between these conditions

In conclusion, while both surgical repair and TEER are available options for severe MR due to mitral valve prolapse, surgical repair remains the gold standard with superior long-term outcomes. TEER should be reserved for patients at high surgical risk who meet specific anatomical criteria.