What is the management approach for mitral valve prolapse with mitral regurgitation?

Management of Mitral Valve Prolapse with Mitral Regurgitation

Surgical intervention is strongly recommended for patients with severe mitral regurgitation due to mitral valve prolapse who are symptomatic or have evidence of left ventricular dysfunction (LVEF <60% or LVESD ≥40 mm), with mitral valve repair being strongly preferred over replacement whenever anatomically feasible. 1

Assessment and Classification

• Echocardiography is essential to assess the etiology of mitral regurgitation, valve anatomy, function, and severity using an integrative approach 1
• Mitral regurgitation (MR) should be classified as:
  • Primary MR: Structural abnormality of valve leaflets and chordae (as in mitral valve prolapse) 1
  • Secondary MR: Normal valve structure with MR resulting from LV geometry alterations 1
• Severity assessment should include quantitative parameters:
  • Severe primary MR: EROA ≥0.4 cm², regurgitant volume ≥60 mL 1
  • Severe secondary MR: Lower thresholds apply (EROA ≥0.2 cm², regurgitant volume ≥30 mL) 1

Management Algorithm for Primary MR due to Mitral Valve Prolapse

Asymptomatic Patients with Severe MR

• Surgical intervention is recommended when any of the following are present:

  • LV ejection fraction <60% 1, 2
  • LV end-systolic dimension ≥40 mm 1, 2
  • New-onset atrial fibrillation 1
  • Pulmonary hypertension (resting PASP >50 mmHg) 1, 2
  • Progressive increase in LVESD approaching 40 mm on serial echocardiograms 1
  • Progressive decrease in LVEF approaching 60% on serial echocardiograms 1

• Regular monitoring if none of the above criteria are met:

  • Clinical follow-up every 6 months 2
  • Echocardiography annually 2

Symptomatic Patients with Severe MR

• Surgical intervention is recommended regardless of LV function 1, 2

Moderate MR

• Clinical follow-up every 6-12 months 2
• Echocardiography every 1-2 years 2
• Consider more frequent monitoring if borderline measurements or significant changes since previous visit 2

Surgical Considerations

Surgical Techniques for Primary MR

• Mitral valve repair is strongly preferred over replacement when technically feasible 1, 2

• Repair techniques based on specific pathology:

  • Focal posterior leaflet flail: Nonresection techniques (PTFE neochord reconstruction or chordal transfer) or focal triangular resection with annuloplasty ring 1, 2
  • Bileaflet prolapse: Nonresection techniques with annuloplasty ring 1, 2
  • Diffuse myxomatous disease: Sliding leaflet valvuloplasty with annuloplasty ring 1, 2

• Factors affecting repair success:

  • Surgeon experience and center volume significantly impact outcomes 1, 2
  • Patients with single segment flail of posterior leaflet have highest chance of successful repair 1
  • Complex pathologies (anterior, bileaflet, Barlow's disease) should be referred to experienced mitral valve surgeons 1

Transcatheter Options

• Percutaneous edge-to-edge repair may be considered for patients at high surgical risk 1

Medical Therapy

• No evidence supports the use of vasodilators including ACE inhibitors in chronic primary MR without heart failure 2
• For patients with heart failure symptoms who are not surgical candidates:
  • ACE inhibitors 2
  • Beta-blockers 2
  • Spironolactone as appropriate for heart failure management 2
• Anticoagulation (target INR 2-3) for patients with:
  • Atrial fibrillation (permanent or paroxysmal) 2
  • History of systemic embolism 2
  • Evidence of left atrial thrombus 2

Long-Term Outcomes and Follow-up

• Mitral valve repair provides better long-term survival compared to replacement for both anterior and posterior leaflet prolapse 3
• Reoperation rates are higher after repair of anterior leaflet prolapse compared to posterior leaflet prolapse (28% vs. 11% at 15 years) 3
• After surgical repair/replacement:
  • Establish baseline ECG, chest X-ray, and echocardiography for future comparison 2
  • Regular clinical and echocardiographic follow-up 2

Common Pitfalls and Caveats

• Echocardiographic assessment can overestimate MR severity with high blood pressure, high LV systolic pressure, or single frame measurements in non-holosystolic MR 1
• Echocardiographic assessment can underestimate MR severity with high LA pressures, low LV ejection fraction, or large LA/LV volumes 1
• Hemodynamic conditions during TEE under anesthesia may significantly reduce MR severity compared to awake TTE assessment 1
• Surgical repair should not be delayed until symptoms develop or LV dysfunction occurs, as earlier intervention leads to improved survival and functional outcomes 1