What are the treatment guidelines for a patient with mitral valve regurgitation?

Mitral Valve Regurgitation Treatment Guidelines

Critical First Step: Distinguish Primary from Secondary MR

Treatment of mitral regurgitation fundamentally depends on whether the disease is primary (valve pathology) or secondary (left ventricular dysfunction), as these require completely different management strategies. 1

• Echocardiography is mandatory to determine etiology, assess severity using an integrative approach (not single parameters), evaluate valve anatomy/function, and measure left ventricular dimensions and ejection fraction 1, 2
• Primary MR results from direct valve abnormality (degenerative, prolapse, flail leaflet), while secondary MR results from LV dysfunction with structurally normal valve components 3

---

PRIMARY MITRAL REGURGITATION

Symptomatic Severe Primary MR

Surgery is indicated for all symptomatic patients (NYHA Class II-IV) with severe primary MR and LVEF >30%. 1, 3

• Mitral valve repair is strongly preferred over replacement when anatomically feasible and durable repair is likely 1, 3
• Outcomes depend heavily on surgeon experience and center volume 1
• Early surgery (within 2 months of indication) yields better outcomes than delayed intervention 1

Asymptomatic Severe Primary MR

Surgery is indicated even in asymptomatic patients when LV dysfunction develops (LVEF ≤60% and/or LV end-systolic diameter ≥45 mm). 1, 3

• Lower LVESD thresholds (≥40 mm) apply for patients with flail leaflet 1
• Surgery should be considered for new-onset atrial fibrillation or systolic pulmonary artery pressure >50 mmHg at rest 1

For asymptomatic patients with preserved LV function, surgery may be considered when:

• High likelihood of durable repair exists with low surgical risk AND one of the following: 1
  • Flail leaflet with LVESD ≥40 mm
  • LA volume ≥60 mL/m² BSA in sinus rhythm
  • Systolic pulmonary pressure ≥60 mmHg on exercise 1

Percutaneous Options for Primary MR

Transcatheter edge-to-edge repair (TEER) should be considered for symptomatic patients with severe primary MR at high/prohibitive surgical risk with favorable anatomy and life expectancy ≥1 year 3

---

SECONDARY MITRAL REGURGITATION

Medical Therapy: The Mandatory First Step

Optimal guideline-directed medical therapy for heart failure is mandatory as the first step in ALL patients with secondary MR before considering any intervention. 1, 2, 3

The medical regimen should include: 2, 3

• ACE inhibitors or ARBs
• Beta-blockers
• Mineralocorticoid receptor antagonists (aldosterone antagonists)
• SGLT2 inhibitors
• Sacubitril/valsartan
• Diuretics for fluid overload manifestations 2

Critical: Reassess MR severity after optimized medical treatment, as secondary MR is dynamic and may improve substantially. 1, 2

• Cardiac resynchronization therapy (CRT) should be considered in appropriate candidates, as it may reduce MR severity through increased closing force and resynchronization of papillary muscles 2

Surgical Intervention for Secondary MR

Surgery is indicated (Class I) for patients with severe secondary MR undergoing CABG with LVEF >30%. 1, 3

Surgery may be considered for patients with severe secondary MR and LVEF >30% who remain symptomatic despite optimal medical management (including CRT if indicated) and have low surgical risk. 1

• Important caveat: There is no conclusive evidence for survival benefit after isolated mitral valve intervention in secondary MR 1
• Mitral valve repair is preferred, but replacement should be considered with unfavorable morphological characteristics 1

Percutaneous Options for Secondary MR

Percutaneous edge-to-edge repair (TEER) may be considered for patients with symptomatic severe secondary MR, LVEF >30%, persistent symptoms despite optimal medical therapy, and no indication for coronary revascularization. 2, 3

• This applies to patients at high surgical risk, avoiding futility 1

---

ACUTE SEVERE MR

Acute severe MR requires immediate hemodynamic stabilization: 1, 3

• Nitrates and diuretics to reduce filling pressures 1
• Sodium nitroprusside to reduce afterload and regurgitant fraction 1
• Inotropic agents if hypotension develops 1
• Intra-aortic balloon pump for mechanical support if hemodynamically unstable 1, 3

---

MILD TO MODERATE MR

No specific medical therapy is indicated for asymptomatic patients with isolated mild MR and normal LV function. 4

• Regular clinical evaluation every 6-12 months with annual echocardiography 2, 4
• Monitor for progression to severe MR, development of symptoms, changes in LV size/function, and pulmonary artery pressure 4
• Intervention is generally not indicated for mild MR 4

For moderate MR: 2

• Clinical evaluation every 6-12 months with annual echocardiography
• Exercise echocardiography should be considered when exercise-induced symptoms are present 2, 4

---

CRITICAL PITFALLS TO AVOID

Delaying surgical intervention until symptoms become severe or LV dysfunction occurs leads to worse outcomes and may result in irreversible cardiac damage. 4

• Vasodilators (including ACE inhibitors) are NOT recommended in chronic primary MR without heart failure, as they provide no benefit 1
• Exception: In hypertrophic cardiomyopathy or mitral valve prolapse, vasodilators can paradoxically increase MR severity 5
• Failing to recognize the dynamic nature of secondary MR can lead to inappropriate management decisions—always reassess after optimal medical therapy 2, 4
• Close clinical follow-up is essential when doubt exists about feasibility of valve repair 1

---

SURVEILLANCE PROTOCOLS

For severe MR: 2

• Clinical evaluation every 6 months
• Annual echocardiography
• Consider exercise echocardiography, biomarkers, and novel measurements of LV function for risk stratification 3

Refer to cardiology when: 4

• MR progresses to moderate or severe
• Symptoms develop despite optimal medical therapy
• LV function deteriorates
• Pulmonary hypertension develops