Approach

Management of MR requires involvement of a multidisciplinary heart team; the risks and benefits of interventional options should be individually evaluated for each patient. It is important to determine whether the patient has primary or secondary MR, as this will affect treatment decisions.

Acute severe MR

Acute severe MR presents as a medical emergency and immediate surgery is indicated.[10][11] Prior to surgery, afterload reduction using diuretics, sodium nitroprusside, and/or intra-aortic balloon counterpulsation may be required to stabilise the patient.[10][11]

Chronic severe primary MR: asymptomatic patients

There is no medical treatment for asymptomatic patients with chronic severe primary MR and preserved left ventricular function that has been shown to improve clinical outcomes; however, these patients are closely monitored and treated for relevant comorbidities such as hypertension.[10][11]

Asymptomatic patients with severe MR are monitored with echocardiography every 6 to 12 months in an effort to identify early signs of left ventricular dysfunction, which can become irreversible before the onset of symptoms.[10][11]

Indications for surgery include depressed left ventricular function and elevated left atrial pressures. For asymptomatic patients, surgery is indicated if the left ventricular ejection fraction (LVEF) is ≤60% or the left ventricular end-systolic diameter (LVESD) is ≥40 mm.[1][10][11][23][24][25]

In general, the threshold for surgical treatment of asymptomatic severe primary MR has been declining because of significant success with mitral valve repair with low operative risk. Patients with LVEF >60% or LVESD <40 mm may be considered for surgery in the case of new-onset atrial fibrillation or elevated systolic pulmonary artery pressure, or when there is significant left atrial dilatation (left atrial volume ≥60 mL/m² or diameter ≥55 mm), a high likelihood of durable repair, and a low surgical risk.[11] US guidelines also recommend considering surgery in asymptomatic patients with severe primary MR and normal LV systolic function (LVEF >60% and LVESD <40 mm) if there is a high likelihood of durable repair (>95%) and a low surgical risk (<1%), or if there is a progressive increase in LV size or progressive decrease in ejection fraction on ≥3 serial imaging studies.[10][25]

Surgical options include:

  • Mitral valve repair[26]

  • Mechanical valve replacement and anticoagulation or bioprosthetic valve replacement.[27] [ Cochrane Clinical Answers logo ]

When surgery is indicated but not possible or must be delayed, US guidelines advise that guideline-directed medical therapy for systolic dysfunction may be considered.[10]

Asymptomatic patients with severe primary MR and no indications for surgery may be managed with watchful waiting.[11][25]

Chronic severe primary MR: symptomatic patients

Guidelines recommend surgery for symptomatic patients with severe chronic primary MR and acceptable surgical risk.[10][11][25]

For symptomatic patients who are inoperable or at high surgical risk, transcatheter mitral valve intervention (transcatheter edge-to-edge repair) may be considered if mitral valve anatomy is favourable.[10][11][25]

When surgery is indicated but not possible or must be delayed, US guidelines recommend that medical therapy for systolic dysfunction may be considered.[10] European guidelines recommend medical treatment in line with current heart failure guidelines for patients with overt heart failure.[11]

Patients who are refractory to medical therapy and not suitable for surgery or transcatheter repair may receive extended heart failure management: for example, cardiac resynchronisation therapy and ventricular assist devices.[11]

Chronic severe secondary MR

All patients with symptomatic secondary MR should be treated with guideline-directed medical therapy in consultation with a cardiologist expert in the management of heart failure, alongside cardiac resynchronisation therapy for the treatment of atrial fibrillation when indicated.[28] If symptoms persist despite optimal medical management, mitral valve intervention may be indicated.[10][11][25]

For patients with severe secondary MR who are undergoing revascularisation with coronary artery bypass grafting (CABG), mitral valve surgery is recommended concomitantly.[10][11][25] European guidelines also recommend considering surgery when revascularisation is not indicated and the patient remains symptomatic despite optimal medical management and they have a low surgical risk.[11] If surgical risk is not low, transcatheter mitral valve intervention may be considered.[11]

US guidelines recommend considering mitral valve surgery for patients with severe secondary MR who are undergoing revascularisation with CABG and also in severely symptomatic patients (New York Heart Association class III or IV) with severe secondary MR due to atrial annular dilation and LVEF ≥50% when symptoms persist despite therapy for heart failure and atrial fibrillation.[10][25] For those with LVEF less than 50% who remain symptomatic despite optimal medical therapy, transcatheter mitral valve repair intervention or valve surgery may be considered.[10][25] Transcatheter edge-to-edge mitral valve repair is preferred for those with appropriate anatomy (LVEF 20% to 50%, LVESD ≤70 mm, pulmonary artery systolic pressure ≤70 mmHg).

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