Treatment for Heart Failure with Multiple Valve Regurgitation
For patients with heart failure, severe mitral regurgitation, aortic valve sclerosis with regurgitation, and severe tricuspid regurgitation, surgical intervention with valve repair or replacement should be considered as the primary treatment option, particularly for patients with refractory symptoms despite optimal medical therapy.
Initial Medical Management
- Diuretics are essential first-line therapy to control fluid retention and symptoms in patients with heart failure and multiple valve regurgitation 1, 2
- ACE inhibitors or ARBs should be included in the treatment regimen for patients with heart failure symptoms, particularly with reduced ejection fraction 2, 3
- Beta-blockers and mineralocorticoid receptor antagonists should be added to the treatment regimen for patients with heart failure with reduced ejection fraction 2
- Meticulous identification and control of fluid retention is crucial for patients with refractory heart failure 1
Assessment and Evaluation
- Echocardiography is essential to determine the severity and mechanism of valve regurgitation, distinguishing between primary (organic) and secondary (functional) valve disease 4, 2
- Exercise echocardiography should be considered when exercise-induced symptoms are present to assess for dynamic worsening of mitral regurgitation 2
- Pulmonary artery catheter placement may be reasonable to guide therapy in patients with refractory heart failure and persistently severe symptoms 1
Surgical Management Options
- Referral to a heart failure program with expertise in managing refractory heart failure is recommended for patients with multiple valve disease 1
- For severe primary mitral regurgitation, surgery is indicated for symptomatic patients with LVEF >30% 4
- Mitral valve repair is strongly preferred over replacement when anatomically feasible and durable repair is likely 4
- For severe secondary mitral regurgitation, surgery should be considered for patients undergoing CABG with LVEF >30% 4, 2
- The effectiveness of mitral valve repair or replacement is not well established for severe secondary mitral regurgitation in refractory end-stage heart failure 1
- The presence of significant tricuspid regurgitation with mitral valve disease represents a high-risk population with potentially worse surgical outcomes 5, 6
Advanced Treatment Options
- Referral for cardiac transplantation should be considered for potentially eligible patients with refractory end-stage heart failure 1
- Consideration of a left ventricular assist device as permanent or "destination" therapy is reasonable in highly selected patients with refractory end-stage heart failure and an estimated 1-year mortality over 50% with medical therapy 1
- Transcatheter edge-to-edge repair (TEER) may be considered for symptomatic patients with severe primary mitral regurgitation at high/prohibitive surgical risk with favorable anatomy 4
- TEER may also be considered for patients with severe secondary mitral regurgitation, LVEF >30%, persistent symptoms despite optimal medical therapy, and no indication for coronary revascularization 4
Special Considerations
- The presence of multiple valve disease, particularly the combination of mitral and tricuspid regurgitation, identifies a high-risk population 5
- Patients with severe tricuspid regurgitation in addition to mitral valve disease have significantly higher mortality rates, regardless of treatment strategy 5, 7
- Severe tricuspid regurgitation may develop late after mitral valve surgery, so close monitoring is essential 8
- Functional tricuspid regurgitation may improve after correction of left-sided valve disease, particularly when pulmonary hypertension is severe and the tricuspid valve anatomy is not grossly distorted 9
Follow-up Protocol
- Regular clinical and echocardiographic follow-up every 6-12 months is recommended for patients with severe valve regurgitation 4, 2
- Reassessment of secondary mitral regurgitation severity after optimized medical treatment is essential before deciding on intervention 2
- Options for end-of-life care should be discussed with patients and families when severe symptoms persist despite application of all recommended therapies 1
Common Pitfalls
- Delaying surgical intervention until symptoms become severe or left ventricular dysfunction occurs can lead to worse outcomes 2
- Failing to recognize the dynamic nature of secondary mitral regurgitation can lead to inappropriate management decisions 2
- Underestimating the impact of tricuspid regurgitation on outcomes, as it is associated with higher mortality even after treatment of other valve lesions 5, 7