What are the criteria for surgical intervention in patients with severe mitral regurgitation (MR)?

Surgical Intervention Criteria for Severe Mitral Regurgitation

Surgery is indicated in patients with severe mitral regurgitation who are symptomatic with preserved left ventricular function (LVEF >30%) or in asymptomatic patients with left ventricular dysfunction (LVEF ≤60% and/or LVESD ≥40 mm). 1

Primary Mitral Regurgitation

Symptomatic Patients

• Surgery is indicated in symptomatic patients with LVEF >30% and LVESD <55 mm 1
• Surgery is indicated in symptomatic patients with preserved LV systolic function (LVEF >30%) 1
• For symptomatic patients with LVEF <30%, mitral valve surgery may be considered if refractory to medical therapy with high likelihood of durable repair and low comorbidity 1
• Transcatheter edge-to-edge repair (TEER) is reasonable in appropriate symptomatic patients with prohibitive surgical risk and favorable anatomy (LVEF 20-50%, LVESD ≤70 mm, PASP ≤70 mmHg) 1

Asymptomatic Patients

• Surgery is indicated in asymptomatic patients with LV dysfunction (LVEF ≤60% and/or LVESD ≥40 mm) 1
• Surgery should be considered in asymptomatic patients with preserved LV function and:
  • New-onset atrial fibrillation or pulmonary hypertension (PASP >50 mmHg) 1
  • Flail leaflet and LVESD ≥40 mm with high likelihood of durable repair 1
  • Significant left atrial dilatation (volume index ≥60 mL/m² or diameter >55 mm) when performed at a heart valve center with likely durable repair 1
• Surgery may be considered in asymptomatic patients with preserved LV function when there is >95% likelihood of successful repair and expected mortality <1% at experienced centers 1
• Progressive increase in LV size or decrease in EF on ≥3 serial imaging studies may warrant consideration for surgery 1

Secondary Mitral Regurgitation

• Valve surgery may be considered in symptomatic patients with severe secondary MR despite optimal guideline-directed medical therapy (GDMT) 1
• MV surgery is recommended for patients with severe secondary MR undergoing CABG and LVEF >30% 1
• For patients with moderate ischemic MR undergoing CABG:
  • MV repair is reasonable if no viability in posteroinferior wall 1
  • CABG without MV surgery may be considered if viability is present in posteroinferior wall 1

Choice of Intervention

• Mitral valve repair is the preferred technique when a durable repair is expected 1
• In primary MR, repair should be performed at experienced centers with high success rates 1
• For secondary MR, repair with undersized rigid annuloplasty ring is preferred in selected patients without advanced LV remodeling 1
• Chordal-sparing MV replacement may be considered in cases with high risk of MR recurrence 1

Percutaneous Intervention

• TEER may be considered in symptomatic patients with primary MR who meet echo criteria of eligibility and are at high/prohibitive surgical risk 1
• For secondary MR, TEER should be considered in symptomatic patients with LVEF >30% who have no indication for coronary revascularization after optimal GDMT 1

Special Considerations

• Urgent surgery is indicated in patients with acute severe MR 1
• Concomitant MV surgery is recommended for patients with severe primary MR undergoing cardiac surgery for other indications 1
• Early surgery may be beneficial in asymptomatic patients to prevent adverse outcomes, particularly when preoperative atrial fibrillation is present 2
• Medical therapy (beta-blockers, ACE inhibitors) may help manage symptoms in patients not yet meeting surgical criteria but does not replace the need for timely intervention 3, 4

Monitoring Recommendations

• Asymptomatic severe MR: follow-up every 6-12 months 1
• Asymptomatic moderate MR with preserved LV function: yearly with echocardiography every 1-2 years 1
• More frequent reassessment if LV dilation is occurring 1
• Consider exercise echocardiography, Holter monitoring, and CMR for risk stratification 1

Pitfalls to Avoid

• Delaying surgery until symptoms are severe or LV function significantly deteriorates can result in worse outcomes 5, 4
• Failing to recognize new-onset atrial fibrillation as a trigger for surgical intervention in otherwise asymptomatic patients 2
• Not referring patients to experienced mitral valve centers where repair rates are high and outcomes better 1
• Overlooking the potential for successful valve repair in elderly patients who may benefit from intervention 5