Mitral Valve Replacement is the Most Appropriate Management
For this patient with rheumatic severe mitral regurgitation, NYHA class III symptoms, preserved ejection fraction (60%), and bi-atrial enlargement, mitral valve replacement (or repair if feasible) should be performed now—not medical management alone and not routine follow-up.
Rationale: Symptomatic Severe MR is a Class I Indication for Surgery
This patient meets clear guideline criteria for surgical intervention:
Symptomatic severe primary MR with LVEF >30% is a Class I indication for mitral valve surgery 1, 2. The ACC/AHA guidelines explicitly state that mitral valve surgery is recommended for symptomatic patients with chronic severe MR and LVEF greater than 30% 1.
NYHA class III represents significant symptoms that warrant immediate intervention, not medical temporizing 3, 2. These patients have marked limitation of physical activity and are comfortable only at rest—this degree of heart failure mandates surgical correction 1.
The preserved EF of 60% does not contraindicate surgery—in fact, it represents the optimal window for intervention before irreversible myocardial dysfunction develops 4, 3. Guidelines recognize that patients can be severely symptomatic despite preserved LVEF because MR creates volume overload and pulmonary congestion independent of systolic function 3.
Why Medical Management Alone (Option A) is Inadequate
While diuretics and ACE inhibitors have a role in managing heart failure symptoms:
Medical therapy does not address the underlying mechanical problem of severe valvular regurgitation 5, 6. Surgery is the only treatment proven to improve symptoms and prevent heart failure in severe MR 5.
Delaying surgery in symptomatic patients leads to irreversible LV dysfunction and worse outcomes 4. The concept of "mitral regurgitation begets mitral regurgitation" means ongoing severe MR perpetuates a cycle of progressive LV dilation and worsening regurgitation 1, 3.
Medical therapy may provide temporary symptom relief but does not alter the natural history of severe symptomatic MR, which carries a yearly mortality of approximately 6% in patients over 50 years 5.
Why Follow-Up (Option C) is Inappropriate
Routine follow-up every 3-6 months is reserved for asymptomatic patients:
Asymptomatic severe MR with preserved LV function warrants surveillance every 6-12 months 1, 2, but this patient is symptomatic with NYHA class III symptoms.
Once symptoms develop, the indication for surgery becomes urgent (Class I) 1, 2. Waiting for further deterioration risks irreversible myocardial damage and increased operative mortality 4, 5.
Bi-atrial enlargement indicates chronic hemodynamic burden and suggests the disease has already progressed beyond the ideal asymptomatic window for intervention 3.
Surgical Approach: Repair vs Replacement in Rheumatic Disease
The question specifies rheumatic etiology, which has important implications:
Mitral valve repair is generally preferred over replacement when feasible 1, as it preserves LV function and avoids prosthetic valve complications 1.
However, rheumatic MR often involves extensive valve distortion (thickened leaflets, fused commissures, shortened chordae) that may preclude durable repair 1. The guidelines acknowledge that rheumatic disease may necessitate valve replacement when the apparatus is too distorted 1.
If repair is attempted in rheumatic disease, it should be performed at a comprehensive valve center with expertise in complex repairs 1. The success rate for rheumatic MR repair is lower than for degenerative disease 1.
If replacement is required, chordal-sparing techniques should be used to preserve LV function 1.
Critical Pitfalls to Avoid
Do not be falsely reassured by the "preserved" EF of 60%—in MR, this actually represents early myocardial dysfunction because the reduced afterload from regurgitation artificially elevates the EF 4, 3. Guidelines suggest LVEF should ideally be >64% in severe MR 4.
Do not delay surgery waiting for EF to decline to <60% or LVESD to reach ≥40 mm—by that point, LV dysfunction may be irreversible 4. Symptomatic patients should undergo surgery regardless of these thresholds 1, 2.
Do not treat this as secondary (functional) MR—rheumatic MR is primary (organic) valve disease with different surgical indications 1. Secondary MR has more controversial indications for isolated valve surgery 1.
Immediate Management Algorithm
Initiate diuretics and ACE inhibitors for symptom relief while arranging urgent surgical evaluation 7—but recognize these are bridge therapies, not definitive treatment.
Refer immediately to cardiac surgery at a center with experience in rheumatic valve disease and high repair rates if repair is contemplated 1, 4.
Perform transesophageal echocardiography to define valve anatomy and assess repairability 1.
Proceed to mitral valve surgery (repair if feasible, replacement if necessary) without delay 1, 2.
If repair is performed with annuloplasty ring, anticoagulate with warfarin (INR 2.0-3.0) for 3 months 4; if mechanical valve replacement is required, lifelong warfarin (INR 2.5-3.5) is necessary 4.