In an asymptomatic patient with normal left‑ventricular systolic function (ejection fraction 55‑60 %), normal diastolic filling, mild bi‑atrial enlargement, moderate eccentric pulmonic valve regurgitation and mild mitral and tricuspid valve regurgitation without evidence of pulmonary hypertension, what is the recommended management?

Management of Asymptomatic Patient with Moderate Pulmonic Regurgitation and Mild Mitral/Tricuspid Regurgitation

This patient requires conservative management with regular clinical and echocardiographic surveillance; no surgical intervention is indicated at this time.

Clinical Assessment and Risk Stratification

Your patient presents with:

• Normal LV systolic function (EF 55-60%) and normal diastolic function
• Moderate eccentric pulmonic valve regurgitation (the primary valvular abnormality)
• Mild mitral and tricuspid regurgitation (hemodynamically insignificant)
• Mild bi-atrial enlargement (likely related to chronic volume load)
• No pulmonary hypertension (critical exclusion)
• Asymptomatic status

The mild mitral and tricuspid regurgitation do not warrant surgical intervention, as isolated surgery is not indicated for mild or moderate regurgitation in asymptomatic patients with preserved LV function 1. The mild tricuspid regurgitation with normal valves and normal ejection fraction does not cause hemodynamically significant volume overload and does not meet criteria for surgical intervention 2.

Surveillance Protocol

Clinical Monitoring

• Clinical evaluation every 6 months to assess for new symptoms, particularly exertional dyspnea, decreased exercise tolerance, or fatigue 1, 3
• Instruct the patient to report immediately any change in functional status, especially new dyspnea or reduced exercise capacity 1, 4

Echocardiographic Monitoring

• Echocardiography every 12 months to monitor 1, 3:
  • LV ejection fraction and LV end-systolic dimension (LVESD)
  • Severity of all valvular regurgitation (pulmonic, mitral, tricuspid)
  • Right ventricular size and function
  • Pulmonary artery systolic pressure
  • Left atrial volume index
  • Development of new atrial fibrillation

The mild bi-atrial enlargement requires monitoring but does not currently indicate intervention 1.

Critical Thresholds for Escalation to Surgical Referral

For Mitral Regurgitation (if progression occurs)

• LV ejection fraction decreases to <60% with LVESD ≥40 mm 1
• New-onset atrial fibrillation 1
• Resting pulmonary artery systolic pressure >50 mmHg (or >60 mmHg with exercise) 1
• Development of symptoms (NYHA Class II-IV) even with preserved LV function 1
• Progressive LV dilation on serial imaging 3, 4

For Tricuspid Regurgitation (if progression occurs)

• Monitor tricuspid annular diameter, right ventricular function with TAPSE and S' velocity, and development of pulmonary hypertension 2
• Severe tricuspid regurgitation would warrant intervention, especially if concomitant left-sided valve surgery is needed 5

Medical Management

Current Recommendations

• No specific vasodilator therapy is indicated for this patient with mild-to-moderate regurgitation and preserved LV function 1, 4
• No anticoagulation is currently indicated in the absence of atrial fibrillation, prior systemic embolism, or left atrial thrombus 1

If Atrial Fibrillation Develops

• Initiate anticoagulation with target INR 2.5-3.5 1, 4

If Hypertension is Present

• Control blood pressure, as it can affect mitral regurgitation severity 4

Diagnostic Considerations

Exercise Testing

• Consider stress echocardiography if there is discrepancy between symptoms and resting findings, as mitral regurgitation severity may increase with exercise 1, 4
• This is particularly important because the patient is currently asymptomatic but has mild bi-atrial enlargement suggesting chronic volume load 3, 4

Advanced Imaging

• Transesophageal echocardiography (TEE) may be necessary for more accurate assessment of the eccentric pulmonic regurgitation jet 4
• Cardiovascular magnetic resonance (CMR) may be valuable if echocardiographic assessment is inconclusive regarding regurgitation severity or ventricular function 4

Common Pitfalls to Avoid

Do Not Attribute All Findings to Cardiac Pathology

• In patients with obesity or other comorbidities, peripheral edema may be multifactorial and not solely related to mild tricuspid regurgitation 2

Do Not Delay Monitoring

• The EF of 55-60% sits at the upper threshold of normal; in the context of mitral regurgitation, this may actually reflect early ventricular dysfunction since MR typically augments ejection fraction measurements 4
• Regular surveillance is crucial as moderate regurgitation can progress to severe over time 4

Do Not Pursue Premature Surgical Intervention

• Surgery is not indicated for asymptomatic patients with mild-to-moderate regurgitation and preserved LV function (EF >60% and LVESD <40 mm) when significant doubt about the feasibility of repair exists 1
• The American College of Cardiology recommends against pursuing surgical intervention for mild tricuspid regurgitation 2

Special Considerations

If Cardiac Surgery Becomes Necessary for Other Indications

• Concomitant mitral valve repair may be considered even for moderate MR if the patient requires cardiac surgery for another indication 1, 4
• Concomitant tricuspid valve surgery should be considered at the time of left-sided valve surgery if tricuspid regurgitation progresses or if significant tricuspid annular dilatation develops 5

Preferred Intervention When Needed

• If mitral valve intervention becomes necessary, repair is strongly preferred over replacement when anatomically feasible, as it preserves LV function, avoids prosthetic valve complications, and improves long-term outcomes 1, 3, 4