What is the management of mitral valve moderate to severe regurgitation?

Management of Moderate to Severe Mitral Regurgitation

For moderate to severe mitral regurgitation, management depends critically on whether the MR is primary (valve pathology) or secondary (ventricular dysfunction), with primary MR requiring surgical intervention when specific thresholds are met, while secondary MR demands optimization of heart failure therapy before considering intervention. 1, 2

Initial Assessment and Classification

Distinguish Primary vs Secondary MR

• Primary MR results from direct valve abnormalities (degenerative disease, prolapse, flail leaflet, rheumatic disease) 1, 2
• Secondary MR results from left ventricular geometry alterations with structurally normal valve leaflets 1, 2
• Use comprehensive echocardiography to determine etiology, severity, valve anatomy, and LV function 1

Severity Confirmation

• Apply an integrative approach using multiple echocardiographic parameters rather than single measurements 1
• Key quantitative parameters for severe MR: EROA ≥0.4 cm², regurgitant volume ≥60 mL/beat, regurgitant fraction ≥50% 1
• For secondary MR, EROA ≥0.3 cm² may indicate severity if the orifice is elliptical; some guidelines use ≥0.2 cm² 1
• Critical caveat: Secondary MR is highly dynamic and varies with loading conditions, blood pressure, and medical therapy—reassess severity after optimizing medical management 1

Management of Primary Mitral Regurgitation

Symptomatic Patients (NYHA Class II-IV)

• Surgery is indicated for all symptomatic patients with severe primary MR and LVEF >30% 1, 2
• Mitral valve repair is strongly preferred over replacement when anatomically feasible and durable repair is likely 1, 2
• For patients with LVEF ≤30%, surgery may still be considered if symptomatic despite optimal medical therapy 1
• Early surgery (within 2 months) after indication is reached improves outcomes compared to delayed intervention 1

Asymptomatic Patients

Surgery is indicated when any of the following are present: 1, 2

• LV dysfunction: LVEF ≤60% and/or LV end-systolic diameter (LVESD) ≥40 mm 1, 2
• New-onset atrial fibrillation secondary to MR 1
• Pulmonary hypertension: PA systolic pressure ≥50 mmHg at rest 1

Surgery should be considered (lower level recommendation) when: 1

• Flail leaflet with LVESD ≥40 mm in centers with >95% repair success and <1% mortality 1
• Severe LA dilatation (volume index ≥60 mL/m²) in sinus rhythm with high likelihood of durable repair 1
• Progressive LV dilatation or decreasing EF on serial imaging (≥3 studies) 1

Surveillance for Asymptomatic Severe Primary MR

• Every 6 months if LVEF >60% and LVESD <40 mm 1, 2
• Consider exercise echocardiography, biomarkers (BNP/NT-proBNP), and global longitudinal strain for risk stratification 1, 2
• More frequent monitoring if LV is dilating or parameters are approaching intervention thresholds 1

Management of Secondary Mitral Regurgitation

Optimize Medical Therapy FIRST

This is the critical first step before considering any intervention: 1, 2

• Guideline-directed medical therapy for heart failure: ACE inhibitors/ARBs, beta-blockers, mineralocorticoid receptor antagonists 2
• Add SGLT2 inhibitors and sacubitril/valsartan for contemporary heart failure management 2
• Cardiac resynchronization therapy (CRT) if indicated by standard heart failure criteria 1
• Revascularization if ischemic etiology with viable myocardium 1
• Reassess MR severity after optimization—many patients will have significant reduction in MR 1

Important pitfall: Do not label patients as having severe secondary MR until they are on optimally tolerated doses of guideline-directed medical therapy 1

Surgical Intervention for Secondary MR

• Surgery is recommended for patients with severe secondary MR undergoing CABG with LVEF >30% 1, 2
• Surgery may be considered (Class IIb) for symptomatic patients with severe secondary MR despite optimal medical therapy (including CRT if indicated), judged appropriate by the heart team 1
• Use undersized rigid annuloplasty ring for repair in ischemic MR 1
• Surgery for moderate secondary MR undergoing CABG may be considered if no viability in posteroinferior wall 1

Transcatheter Edge-to-Edge Repair (TEER)

TEER is reasonable for carefully selected patients with severe secondary MR who meet ALL criteria: 1, 2

• Symptomatic heart failure (NYHA II-III or ambulatory IV) despite optimized medical therapy 1
• LVEF 20-50% 1
• LVESD ≤70 mm 1
• PA systolic pressure ≤70 mmHg 1
• At least one heart failure hospitalization within the previous year or elevated natriuretic peptides 1
• Anatomy judged suitable for TEER on TEE 1
• No indication for coronary revascularization 2

Exclusions for TEER: Severe disability/frailty, infiltrative cardiomyopathies, hemodynamic instability, moderate-severe RV dysfunction, mitral valve area <4.0 cm² 1

Special Situations

Acute Severe MR

• Immediate medical stabilization: vasodilators (nitroprusside, nitrates), diuretics to reduce filling pressures 1, 2
• Inotropic support if hemodynamically unstable 2
• Intra-aortic balloon pump may be needed for mechanical support 2
• Urgent surgery is indicated once stabilized 1

Concomitant Cardiac Surgery

• MV repair or replacement is recommended for patients with severe primary MR undergoing cardiac surgery for other indications 1
• MV surgery is reasonable for severe secondary MR undergoing CABG 1
• For moderate MR undergoing CABG, surgery may be considered if no viability in posteroinferior wall 1

High/Prohibitive Surgical Risk with Primary MR

• Consider TEER for symptomatic patients with favorable anatomy and life expectancy ≥1 year 2

Medical Therapy Considerations

Role in Primary MR

• Beta-blockers may lessen MR severity, prevent LV dysfunction deterioration, and improve survival in asymptomatic patients with moderate-severe primary MR 3
• ACE inhibitors/ARBs may reduce MR, especially in asymptomatic patients 3
• Critical caveat: In mitral valve prolapse or hypertrophic cardiomyopathy, vasodilators can increase MR severity—use with caution 1, 3
• Medical therapy is not a substitute for surgery when guideline indications are met, but may delay progression 3

Hypertensive Urgency/Emergency

• Acute severe MR can present with hypertensive crisis and improve substantially with blood pressure control 1
• Reassess MR severity after achieving normotension before making definitive management decisions 1

Common Pitfalls to Avoid

• Do not rely on color Doppler jet area alone—it overestimates MR with high blood pressure and underestimates with high LA pressure 1
• Do not delay surgery in symptomatic primary MR—even mild symptoms at time of surgery are associated with worse post-operative outcomes 1
• Do not assess secondary MR severity during TEE under general anesthesia—reduced preload and blood pressure significantly underestimate severity compared to awake TTE 1
• Do not proceed with intervention for secondary MR without first optimizing medical therapy—MR severity is highly dynamic 1
• Do not use LVESD thresholds rigidly—adjust for body surface area in patients of small stature (≥22 mm/m²) 1