Should a patient with new onset severe aortic and tricuspid regurgitation, but normal Left Ventricular Ejection Fraction (LVEF) and no left-sided heart dysfunction, following mitral valve repair surgery, be considered as having Heart Failure with Preserved Ejection Fraction (HFpEF) and started on cardiac medications such as Angiotensin-Converting Enzyme inhibitors (ACEi) or Angiotensin II Receptor Blockers (ARB)?

Post-Mitral Valve Repair with New Severe Aortic and Tricuspid Regurgitation: Management Approach

This patient should NOT be classified as HFpEF and does not require standard HFpEF medical therapy (ACEi/ARB) at this time. The severe valvular regurgitation represents acute/subacute structural pathology requiring surgical evaluation, not chronic heart failure syndrome.

Key Clinical Distinction

This patient has acute volume overload from new severe valvular regurgitation post-surgery, which is fundamentally different from HFpEF:

• HFpEF requires: symptoms of heart failure, preserved EF >50%, AND evidence of chronic diastolic dysfunction or structural heart disease 1
• This patient has: acute valvular pathology causing volume overload immediately post-operatively, without established chronic heart failure syndrome
• The preserved LVEF and normal left-sided function indicate the ventricle has not yet adapted to or been damaged by chronic volume overload 2

Immediate Management Priority: Surgical Evaluation

Urgent cardiac surgery consultation is indicated for the following reasons:

Severe Aortic Regurgitation

• Surgery is indicated in all symptomatic patients with severe aortic regurgitation regardless of LVEF 3
• Surgery is indicated in asymptomatic patients with resting LVEF ≤50% or evidence of LV dysfunction 3
• Even with currently preserved function, severe AR will lead to progressive LV dilation and dysfunction if left untreated 3

Severe Tricuspid Regurgitation

• Surgery is indicated for severe primary tricuspid regurgitation in symptomatic patients without severe RV dysfunction 3
• Surgery is indicated for severe secondary TR when undergoing left-sided valve surgery 3
• Isolated severe TR post-mitral surgery can progress and cause significant late mortality if not addressed early 4
• Delaying intervention until NYHA class IV develops is associated with poor surgical outcomes and postoperative complications 4

Why Standard HFpEF Medications Are Not Indicated

ACEi/ARB therapy has no proven benefit in this clinical scenario:

• ACEi/ARB have not been proven effective in HFpEF and showed only moderate efficacy with no clear benefit in clinical trials 5, 1
• These medications are disease-modifying for HFrEF (reduced EF), where they reverse LV dilation 1
• This patient's problem is structural valve disease requiring mechanical correction, not neurohormonal activation requiring pharmacologic blockade 6
• The volume overload is acute/subacute post-surgical, not chronic compensated heart failure 7

Appropriate Medical Management While Awaiting Surgery

Diuretics are the primary medical therapy:

• Diuretics control volume overload and congestive symptoms from severe regurgitation 7
• One case report showed increased diuresis successfully controlled heart failure symptoms in a patient with severe MR post-TVR 7
• This provides symptomatic relief but does not address the underlying structural problem 7

Avoid medications that may worsen hemodynamics:

• Beta-blockers may reduce forward cardiac output in severe regurgitant lesions
• Excessive afterload reduction may worsen regurgitant fraction

Clinical Pitfalls to Avoid

Do not delay surgical referral based on "normal" LVEF:

• LVEF may appear "normal" or supranormal in severe MR due to reduced afterload, masking early myocardial dysfunction 2
• In severe MR, LVEF should ideally be >64%; a "normal" LVEF of 50-60% may actually represent early dysfunction 2
• Waiting for LVEF to decline before surgery results in worse outcomes 3

Do not misclassify as HFpEF:

• HFpEF is a chronic syndrome with diastolic dysfunction, not acute valvular pathology 1
• The timing (directly post-cardiac surgery) and acuity distinguish this from chronic HFpEF 7

Do not underestimate the severity of combined lesions:

• Severe AR + severe TR creates biventricular volume overload
• Progressive TR after mitral surgery is well-documented and can lead to multiple organ failure if untreated 4
• The combination may cause rapid clinical deterioration despite currently preserved ventricular function 7

Monitoring While Awaiting Surgical Decision

Serial echocardiography every 3-6 months to assess:

• LV end-systolic dimension (surgery indicated if LVESD ≥45mm) 3
• LVEF (surgery indicated if LVEF ≤60% in primary regurgitation) 3
• RV function and pulmonary pressures 3
• Progression of regurgitant lesions 8

Clinical assessment for symptoms:

• Development of dyspnea, exercise intolerance, or heart failure symptoms mandates urgent surgical evaluation 3
• New atrial fibrillation or pulmonary hypertension >50mmHg are additional surgical indications 3