What is the initial approach to managing mitral valve regurgitation?

Management of Mitral Valve Regurgitation

The initial approach to managing mitral valve regurgitation should focus on optimizing medical therapy for heart failure while planning for appropriate surgical or transcatheter intervention based on MR etiology, severity, and patient characteristics. 1

Classification and Assessment

Primary vs. Secondary MR

• Primary MR: Direct valve abnormality (leaflet/chordal pathology)
• Secondary MR: Dysfunction of surrounding structures (LV dilation, papillary muscle displacement)

Key Diagnostic Evaluations

• Echocardiography: Essential for determining:
  • MR severity (EROA, regurgitant volume)
  • LV size and function (LVEF, LVESD)
  • LA size
  • Pulmonary artery pressure
  • Valve anatomy and repair feasibility
• CMR: Consider when echocardiographic measurements are ambiguous or to quantify LV/RV function
• Exercise testing: To unmask symptoms in apparently asymptomatic patients

Management Algorithm for Primary MR

Asymptomatic Severe Primary MR

1. Surgical intervention indicated if:

   • LVEF ≤60% or LVESD ≥40 mm (Stage C2) 1
   • New-onset atrial fibrillation 1
   • Pulmonary hypertension (PASP ≥50 mmHg) 1
   • High likelihood of successful repair (>95%) with low mortality risk (<1%) 1

2. Close monitoring if surgery not indicated:

   • Clinical evaluation every 6-12 months
   • Echocardiography every 6-12 months
   • Monitor for symptoms, LV dysfunction, or LA enlargement

Symptomatic Severe Primary MR

• Surgical intervention recommended regardless of LV function 1
• MV repair strongly preferred over replacement when feasible 1
• Transcatheter edge-to-edge repair (TEER) may be considered in high-risk surgical patients 1

Management Algorithm for Secondary MR

Initial Approach

1. Optimize guideline-directed medical therapy (GDMT) for heart failure:

   • ACE inhibitors/ARBs
   • Beta-blockers
   • Mineralocorticoid receptor antagonists
   • Consider CRT if indicated 1

2. Assess for coronary revascularization needs:

   • CABG or PCI as appropriate for ischemic etiology 1

3. If symptoms persist despite optimal GDMT:

   • Surgical options: MV repair with undersized rigid annuloplasty ring or MV replacement 1
   • Transcatheter edge-to-edge repair (TEER): Consider in appropriate candidates with favorable anatomy 1

Special Considerations

Surgical vs. Transcatheter Approaches

• Primary MR: Surgery is first-line therapy; TEER reserved for high surgical risk 1
• Secondary MR: Decision between surgery and TEER should be made by a multidisciplinary heart team 1

Repair vs. Replacement

• Primary MR: Repair strongly preferred when feasible 1
• Secondary MR: Repair with undersized rigid annuloplasty ring or chordal-sparing replacement 1

Common Pitfalls to Avoid

1. Delaying intervention until symptoms are severe or LV dysfunction is irreversible

   • Early intervention in primary MR with repairable valves has better outcomes

2. Inadequate assessment of MR severity

   • Use integrative approach with multiple echocardiographic parameters
   • Different thresholds for primary vs. secondary MR (EROA ≥0.4 cm² for primary; ≥0.2-0.3 cm² for secondary) 1

3. Failure to optimize medical therapy before considering intervention for secondary MR

   • Complete GDMT optimization may take 3-6 months

4. Not referring to experienced centers

   • Outcomes for MV repair are highly dependent on surgeon experience and center volume 1

By following this structured approach to managing mitral regurgitation, clinicians can ensure appropriate timing of intervention to improve symptoms, prevent heart failure, and optimize survival outcomes.