Can aortic regurgitation improve following mitral valve repair?

Aortic Regurgitation Improvement Following Mitral Valve Repair

Aortic regurgitation can improve following mitral valve repair, particularly in cases where the aortic regurgitation is functional in nature and related to left ventricular geometric changes caused by mitral valve disease. 1

Mechanisms of Improvement

• Mitral valve repair significantly alters left heart hemodynamics, affecting aortic valve function through changes in left ventricular loading conditions and geometry 1
• Successful mitral valve repair leads to significant reduction in left atrial volume and improvement in left ventricular function, which can positively influence aortic valve competence 1
• Correction of mitral regurgitation can lead to favorable ventricular remodeling that may reduce the stress on the aortic valve, potentially improving mild to moderate aortic regurgitation 1

Evidence Supporting Improvement

• The European Society of Cardiology guidelines note that valve interventions can have downstream effects on other valves through ventricular remodeling and altered hemodynamics 2, 1
• Studies have shown that changes in left ventricular geometry following mitral valve repair can affect the aortic annulus and root dimensions, potentially improving aortic valve competence 1

Factors Affecting Likelihood of Improvement

• The severity of pre-existing aortic regurgitation is a key determinant - mild to moderate regurgitation is more likely to improve than severe regurgitation 1, 3
• The etiology of aortic regurgitation matters - functional regurgitation due to ventricular dilatation is more likely to improve than primary valve pathology 1, 4
• The presence of structural abnormalities of the aortic valve (such as bicuspid valve, myxomatous degeneration, or calcification) makes improvement less likely 3, 4

Clinical Implications

• For patients with moderate aortic regurgitation undergoing mitral valve surgery, careful evaluation should determine whether concomitant aortic valve intervention is necessary 1, 3
• The European Society of Cardiology guidelines suggest considering concomitant aortic valve surgery for patients with moderate aortic regurgitation undergoing cardiac surgery for another indication 2, 3
• Similar to how mitral regurgitation can improve after aortic valve replacement (seen in 55.5% of patients with functional mitral regurgitation), the reverse relationship can also occur 5, 6

Monitoring and Follow-up

• Regular echocardiographic follow-up is essential to monitor the progression or improvement of aortic regurgitation after mitral valve repair 1
• If aortic regurgitation persists or worsens despite mitral valve repair, management should focus on optimizing medical therapy with attention to volume control and afterload reduction 1, 3
• If severe aortic regurgitation develops or persists with symptoms or signs of left ventricular dysfunction after mitral valve repair, aortic valve intervention should be considered 1, 3

Potential Pitfalls

• Failing to perform comprehensive pre-operative assessment of all valves, including quantitative assessment of aortic regurgitation severity 1
• Not considering the possibility of concomitant valve procedures in patients with multiple valve disease, especially when moderate aortic regurgitation is present 1, 3
• Overlooking the potential for prosthesis-patient mismatch after mitral valve repair, which can affect hemodynamics and influence aortic valve function 7

Decision-Making Algorithm

1. Assess the severity and mechanism of aortic regurgitation before mitral valve repair 1, 3
2. If aortic regurgitation is severe or has primary structural abnormalities, consider concomitant aortic valve intervention 3
3. If aortic regurgitation is mild to moderate and functional in nature, mitral valve repair alone may be sufficient 1
4. For moderate aortic regurgitation with mixed etiology, consider patient factors such as age, comorbidities, and surgical risk when deciding on concomitant aortic valve intervention 1, 8
5. Schedule close echocardiographic follow-up after mitral valve repair to monitor for changes in aortic regurgitation severity 1