Vasodilator therapy with ACE inhibitors and hydralazine is the mainstay of therapy in patient with chronic compensated mitral regurgitation. Acute mitral regurgitation requires urgent mitral valve repair or mitral valve replacement. MV surgery is indicated in patients with chronic aortic regurgitation who develop symptomatic mitral valve regurgitation. It is also indicated in patients with abnormalities in LV size or function (These include a left ventricular ejection fraction (LVEF) of less than 60% and a left ventricular end systolic dimension (LVESD) of greater than 45 mm), pulmonary hypertension, or new onset atrial fibrillation even without symptoms [1]. The patient with severe LV dysfunction (an LVEF < 30% and/or a left ventricular end-systolic dimension greater than 55 mm) poses a higher risk but may undergo surgery if chordal preservation is likely. MV repair is recommended over MV replacement in the majority of patients with severe chronic MR who require surgery, and patients should be referred to surgical centers experienced in MV repair.
Medical Therapy of Chronic Mitral Regurgitation
Vasodilator therapy is a mainstay of medical therapy in the management of chronic mitral regurgitation. In the chronic state, the most commonly used agents are ACE inhibitors and hydralazine. Studies have shown that the use of ACE inhibitors and hydralazine can delay surgical treatment of mitral regurgitation[2][3].
Surgical Therapy for Chronic Mitral Regurgitation
There are two surgical options for the treatment of mitral regurgitation: mitral valve replacement and mitral valve repair. In general, mitral valve repair is preferred to mitral valve replacement as it carries a lower risk of subsequent prosthetic valve endocarditis and results in better preservation of left ventricular function.
Scenarios Favoring Mitral Valve Repair
The ACC/AHA 2008 guidelines[4] recommend mitral valve repair rather than mitral valve replacement if the anatomy is appropriate, including patients with rheumatic mitral valve disease[5] and mitral valve prolapse[6] (Grade 1C). The procedure should be performed at experienced surgical centers.
Limited damage to certain areas of the mitral valve leaflets or chordae tendineae[7].
"4.Mitral valve repair is recommended in preference to MVR when surgical treatment is indicated for patients with chronic severe primary MR involving the anterior leaflet or both leaflets when a successful and durable repair can be accomplished. (Level of Evidence: B)"
"1.Mitral valve repair is reasonable in asymptomatic patients with chronic severe primary MR (stage C1) with preserved LV function (LVEF >60% and left ventricular end systolic dimension < 40 mm) in whom the likelihood of a successful and durable repair without residual MR is greater than 95% with an expected mortality rate of less than 1% when performed at a heart valve center of excellence. (Level of Evidence: B)"
"2.Mitral valve repair is reasonable for asymptomatic patients with chronic severe non-rheumatic primary MR (stage C1) and preserved LV function (LVEF >60% and left ventricular end systolic dimension <40 mm) in whom there is a high likelihood of a successful and durable repair with:
"3. Concomitant mitral valve repair is reasonable in patients with chronic moderate primary MR (stage B) when undergoing cardiac surgery for other indications. (Level of Evidence: C)"
"2.Mitral valve repair may be considered in patients with rheumatic mitral valve disease when surgical treatment is indicated if a durable and successful repair is likely or when the reliability of long-term anticoagulation management is questionable. (Level of Evidence: B) "
"3. Transcatheter mitral valve repair may be considered for severely symptomatic patients (NYHA class III to IV) with chronic severe primary MR (stage D) who have favorable anatomy for the repair procedure and a reasonable life expectancy but who have a prohibitive surgical risk because of severe comorbidities and remain severely symptomatic despite optimal guideline directed medical therapy for heart failure. (Level of Evidence: B) "
"1.MVR should not be performed for the treatment of isolated severe primary MR limited to less than one half of the posterior leaflet unless mitral valve repair has been attempted and was unsuccessful. (Level of Evidence: B)"
Recommendations for Chronic Secondary Mitral Valve Regurgitation
"1.Mitral valve repair or replacement may be considered for severely symptomatic patients (NYHA
class III to IV) with chronic severe secondary MR (stage D) who have persistent symptoms despite optimal GDMT (guideline directed medical therapy) for heart failure. (Level of Evidence: B) "
"2.Mitral valve repair may be considered for patients with chronic moderate secondary MR (stage B) who are undergoing other cardiac surgery. (Level of Evidence: C) "
2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [1]
Mitral Valve Surgery Indications (DO NOT EDIT) [1]
"1.Mitral valve repair is reasonable in experienced surgical centers for asymptomatic patients with chronic severe MR with preserved LV function (ejection fraction greater than 0.60 and end-systolic dimension less than 40 mm) in whom the likelihood of successful repair without residual MR is greater than 90%. (Level of Evidence: B)"
"1.MV repair is reasonable in experienced surgical centers in the asymptomatic adolescent or young adult with severe congenital MR with preserved LV systolic function if the likelihood of successful repair without residual MR is greater than 90%. (Level of Evidence: B)"
