Is surgery indicated for moderate mitral regurgitation (MR) due to rheumatic mitral valve disease?

Surgery for Moderate Rheumatic Mitral Regurgitation

Surgery is generally NOT indicated for isolated moderate rheumatic mitral regurgitation, but becomes reasonable when performed concomitantly with other cardiac surgery. 1

Primary Recommendation

For isolated moderate rheumatic MR without other surgical indications, medical management is the standard approach. 1 The guidelines reserve surgical intervention for severe MR in rheumatic disease, not moderate MR. 1

When Surgery Becomes Reasonable for Moderate Rheumatic MR

Concomitant mitral valve repair is reasonable (Class IIa) when you are already performing cardiac surgery for other indications (e.g., coronary artery bypass grafting, aortic valve surgery). 1 This recommendation applies because:

• MR is a progressive lesion that may worsen over time 1
• Addressing moderate MR at the time of other cardiac surgery is opportunistic and may prevent future deterioration 1
• However, the added operative risk must be carefully weighed against the potential for MR progression 1

Critical Caveat for Rheumatic Disease

Rheumatic mitral valve disease is significantly less suitable for repair than degenerative disease. 1 Key limitations include:

• Thickened or calcified leaflets reduce repair durability 1
• Extensive subvalvular disease with chordal fusion and shortening complicates repair 1
• Progressive nature of rheumatic disease leads to recurrence 1
• Freedom from reoperation at 20 years is only 50-60% even in experienced hands 1
• In one large Korean series, only 22% of rheumatic patients underwent repair, and one-third developed significant stenosis or regurgitation at 10 years 1

When to Consider Repair in Rheumatic Disease (Class IIb)

Mitral valve repair may be considered in rheumatic disease only when: 1

• A durable and successful repair is highly likely (less advanced disease) 1
• OR when long-term anticoagulation management is questionable or contraindicated (avoiding mechanical valve replacement) 1

Isolated Surgery for Moderate MR: Not Recommended

The increased operative mortality from adding mitral valve surgery might not be justified for treating moderate MR alone. 1 Surgery for isolated moderate MR lacks strong supporting evidence and carries unnecessary risk without clear mortality or morbidity benefit. 1

Medical Management Approach

For moderate rheumatic MR not undergoing other cardiac surgery:

• Optimal medical therapy is the preferred strategy 1
• Serial echocardiographic surveillance to monitor for progression to severe MR 1
• Heart failure medications (ACE inhibitors, beta-blockers) if LV dysfunction develops 1
• Anticoagulation if atrial fibrillation is present 1

Common Pitfalls

• Do not pursue isolated surgery for moderate rheumatic MR - the risk-benefit ratio is unfavorable 1
• Do not assume rheumatic valves are as repairable as degenerative valves - they have much higher failure rates 1
• Do not delay surgery if MR progresses to severe - this leads to irreversible LV dysfunction 1
• Do not ignore the progressive nature of rheumatic disease - even successful repairs may deteriorate over time 1