Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute severe MR

1st line – emergency surgery

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ACUTE
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acute severe MR
1st line – 

emergency surgery

Surgery is indicated for acute severe MR.[10][11] Regurgitation can be corrected by repairing or replacing the supporting valve structures. A prosthetic ring can be inserted to reshape the valve.

Prior to surgery, afterload reduction using diuretics, sodium nitroprusside, and/or intra-aortic balloon counterpulsation may be required to stabilise the patient.[10][11]

ONGOING

chronic severe primary MR: asymptomatic

1st line – surgery

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ONGOING
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chronic severe primary MR: asymptomatic
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left ventricular ejection fraction ≤60% or left ventricular end-systolic diameter ≥40 mm
1st line – 

surgery

For asymptomatic patients, surgery is indicated if they have depressed left ventricular ejection fraction 60% or less, or left ventricular end-systolic diameter 40 mm or more.[1][10][11][23][24][25][26]

Regurgitation can be corrected by repairing the abnormal valve leaflet and/or repairing or replacing the supporting valve structures. A prosthetic ring can be inserted to reshape the valve.

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]

1st line – consider surgery or watchful waiting

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ONGOING
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chronic severe primary MR: asymptomatic
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left ventricular ejection fraction >60% or left ventricular end-systolic diameter <40 mm
1st line – 

consider surgery or watchful waiting

Patients with left ventricular ejection fraction greater than 60% or left ventricular end-systolic diameter less than 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 a high likelihood of durable repair and a low surgical risk.[11] Surgery may also be considered in asymptomatic patients with severe primary MR and normal left ventricular systolic function (left ventricular ejection fraction >60% and left ventricular end-systolic diameter <40 mm) who have a progressive increase in left ventricular size or decrease in ejection fraction on ≥3 serial imaging studies.[10][25]

Regurgitation can be corrected by repairing the abnormal valve leaflet and/or repairing or replacing the supporting valve structures. A prosthetic ring can be inserted to reshape the valve.

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]

chronic primary MR: symptomatic

1st line – surgery

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ONGOING
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chronic primary MR: symptomatic
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acceptable surgical risk
1st line – 

surgery

Surgery is recommended for symptomatic patients with severe chronic primary MR and acceptable surgical risk.[10][11][25]

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

1st line – transcatheter mitral valve intervention or extended heart failure management

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ONGOING
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chronic primary MR: symptomatic
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inoperable or at high surgical risk
1st line – 

transcatheter mitral valve intervention or extended heart failure management

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]

Patients who are 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

1st line – guideline-directed medical therapy

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ONGOING
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chronic severe secondary MR
1st line – 

guideline-directed medical therapy

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]

Consider – surgery

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ONGOING
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chronic severe secondary MR
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coronary artery bypass grafting (CABG) indicated
Consider – 

surgery

Additional treatment recommended for SOME patients in selected patient group

For patients with severe secondary MR who are undergoing revascularisation with CABG, mitral valve surgery may be considered at the same time.[10][11][25]

Consider – surgery

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ONGOING
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chronic severe secondary MR
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persistent symptoms, CABG not indicated, eligible for surgery
Consider – 

surgery

Additional treatment recommended for SOME patients in selected patient group

European guidelines recommend considering surgery when CABG is not indicated and the patient remains symptomatic despite optimal medical management and they have a low surgical risk.[11]

Consider – transcatheter mitral valve intervention

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ONGOING
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chronic severe secondary MR
|
persistent symptoms, CABG not indicated, not eligible for surgery
Consider – 

transcatheter mitral valve intervention

Additional treatment recommended for SOME patients in selected patient group

If the patient remains symptomatic despite optimal medical management and surgical risk is not low, transcatheter mitral valve intervention may be considered, after evaluation for ventricular assist device or heart transplant.[11]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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