From the Guidelines
Mitral regurgitation diagnosis and treatment should prioritize a comprehensive approach, including echocardiography to assess valve anatomy and function, and an integrative assessment of severity, with treatment guided by symptoms, risk stratification, and ventricular function, as recommended by the most recent guidelines 1.
Diagnosis and Assessment
- Echocardiography is essential for assessing the etiology of mitral regurgitation, valve anatomy, and function, as well as the severity of the condition 1.
- An integrative approach is necessary to assess the severity of mitral regurgitation, considering factors such as symptoms, ventricular function, and size, atrial fibrillation, systolic pulmonary pressure, and left atrial size 1.
Treatment Approach
- For severe symptomatic primary mitral regurgitation, surgical intervention, preferably valve repair, is recommended, with consideration of transcatheter edge-to-edge repair for high-risk patients 1.
- For secondary mitral regurgitation, treatment should focus on optimal medical therapy, including guideline-directed management and therapy for heart failure, with consideration of mitral valve intervention in symptomatic patients despite optimal medical therapy, or those with low surgical risk 1.
- Medications such as ACE inhibitors (e.g., enalapril 5-40 mg daily or lisinopril 10-40 mg daily), beta-blockers (e.g., metoprolol 25-200 mg daily), and diuretics (e.g., furosemide 20-80 mg daily) may be used to manage symptoms and prevent heart failure in moderate to severe cases [@Example@].
- Patients should be advised to limit sodium intake to 2,000 mg daily, maintain moderate physical activity as tolerated, and promptly report symptoms like increasing shortness of breath, fatigue, or swelling, with regular follow-up with a cardiologist being essential [@Example@].
Surgical and Interventional Considerations
- Mitral valve repair is the preferred method over replacement, especially when the likelihood of successful repair is high, and should be considered in patients with primary mitral regurgitation who are symptomatic or have evidence of left ventricular dysfunction 1.
- Percutaneous edge-to-edge repair may be considered in patients at high surgical risk or with prohibitive surgical risk, as an alternative to surgical intervention, based on recent clinical trials and guidelines 1.
- The decision for surgical or transcatheter intervention should be made by a multidisciplinary team, considering the patient's overall clinical status, valve anatomy, and the potential benefits and risks of each approach 1.
From the Research
Diagnosis of Mitral Regurgitation
- Mitral regurgitation can be diagnosed on physical exam or by angiography, but is best diagnosed and quantified using echocardiography 2
- A comprehensive 2-dimensional and Doppler echocardiogram is necessary to determine the cause of the mitral valve disease, the severity of the regurgitation, and the effect of the volume overload on the left ventricle 3
- Echocardiography is the preferred diagnostic test to assess the presence and severity of mitral regurgitation 4
Treatment of Mitral Regurgitation
- Acute mitral regurgitation requires urgent mitral valve surgery 2
- Mitral valve repair is the preferred corrective surgery, and only when not possible should mitral valve replacement be performed 2
- Surgery for mitral valve disease is indicated in symptomatic patients with severe valve disease and in asymptotic patients before irreversible ventricular damage occurs 5
- Mitral valve repair via an 'undersized' annuloplasty repair is safe and effectively corrects MR in heart-failure patients 6
- Mitral valve replacement has an increased role in management of functional mitral regurgitation 5
Management Strategies
- Decisions regarding treatment depend on knowledge of the etiology, natural history, and outcome of interventions for these patients with mitral valve disease 3
- Advances in both surgical and catheter-based therapies have resulted in recommendations for lower thresholds for operation and extension of interventional treatments to the older, sicker population of patients with MR 3
- Most patients are managed with strict adherence to the valve guidelines 5
- Early recognition of mitral regurgitation and timely referral for mitral valve surgery significantly improve symptoms and long-term survival 4