Mitral Valve Regurgitation — Management at a Glance

Step 1 — Classify the MR

Step 2 — Assess Severity

• Echocardiography is the cornerstone
• Graded as mild / moderate / severe
• Key parameters: effective regurgitant orifice area (EROA), regurgitant volume, vena contracta, jet area
• Also assess: LV size/function (LVEF, LVESD), pulmonary pressures, LA size

Step 3 — Medical Therapy

Medical therapy does not fix the valve — it manages symptoms and hemodynamics while awaiting or avoiding surgery.

• No proven benefit of vasodilators (e.g., ACE inhibitors) in asymptomatic patients with normal LV function
• Treat comorbidities (hypertension, AF)

• Optimize heart failure therapy first:
  • ACE inhibitors / ARBs
  • Beta-blockers
  • Mineralocorticoid receptor antagonists
  • SGLT2 inhibitors
• CRT (cardiac resynchronization therapy) if LBBB + reduced EF — can reduce functional MR significantly
• Rate control for AF

Step 4 — Indications for Intervention (Severe MR)

Primary MR — Intervene when ANY of the following:

Secondary MR — Intervene when:

• Persistent severe MR despite optimal GDMT
• Patient undergoing CABG or other cardiac surgery

Step 5 — Choose the Intervention

A. Surgical (preferred when anatomy suitable)

• Mitral valve repair — gold standard; preferred over replacement
  • Lower mortality, better LV preservation, no anticoagulation needed
• Mitral valve replacement (MVR) — when repair not feasible
  • Tissue (bioprosthetic) vs. mechanical valve

B. Transcatheter (for high/prohibitive surgical risk)

• TEER — Transcatheter Edge-to-Edge Repair (MitraClip)
  • Class IIa per ACC/AHA guidelines
  • Primary MR: high surgical risk + suitable anatomy
  • Secondary MR: meets COAPT trial criteria (on maximally tolerated GDMT, LVEF 20–50%, LVESD ≤ 70 mm) (Special Competency in Echocardiographic Guidance, p. 7)

Step 6 — Post-Intervention Follow-up

• Echo at 1 month, then annually
• If mechanical valve: lifelong warfarin (target INR 2.5–3.5)
• If bioprosthetic: anticoagulation for 3 months, then aspirin
• Continue HF therapy post-op in secondary MR patients
• Endocarditis prophylaxis per guidelines

Quick Summary Algorithm

Severe MR confirmed on Echo
        ↓
Primary or Secondary?
        ↓
Secondary → Optimize GDMT → CRT if eligible → Reassess
Primary  → Symptomatic or LV dysfunction?
        ↓ YES                        ↓ NO
  Surgical candidate?           Watchful waiting
   Yes → Repair > Replace        (echo q6–12 months)
   No  → TEER (MitraClip)

Key principle: Mitral repair is always preferred over replacement when feasible. In secondary MR, always exhaust medical/device therapy before intervening on the valve itself.