Treatment of Severe Mitral Regurgitation Causing Lower Extremity Edema

Initial Medical Management

The European Society of Cardiology recommends that diuretics are required as first-line therapy for patients with fluid overload manifestations such as lower extremity edema 1
The European Society of Cardiology suggests that ACE inhibitors should be included in the treatment regimen, particularly for patients with heart failure symptoms 1, 3
The European Society of Cardiology recommends that nitrates may be useful for treating acute dyspnea in patients with a large dynamic component of mitral regurgitation 1
The European Society of Cardiology suggests that aldosterone antagonists should be added in the presence of heart failure symptoms 1

The European Society of Cardiology recommends that echocardiography is essential to determine whether the mitral regurgitation is primary or secondary 2, 3
The American College of Cardiology suggests that the dynamic nature of secondary MR must be considered, as severity can change with loading conditions and medical therapy 4
The European Society of Cardiology recommends that exercise echocardiography should be considered when exercise-induced symptoms are present to assess for dynamic worsening of MR 1

The European Society of Cardiology recommends that surgery is indicated for symptomatic patients with severe primary MR 2, 3
The European Society of Cardiology suggests that mitral valve repair is strongly preferred over replacement when technically feasible 3

The European Society of Cardiology recommends that optimal medical therapy is mandatory as the first step in management of all patients with secondary MR 1
The European Society of Cardiology suggests that surgery is indicated in patients with severe secondary MR undergoing coronary artery bypass grafting and LVEF >30% 1, 2
The European Society of Cardiology recommends that percutaneous mitral clip procedure may be considered in patients with symptomatic severe secondary MR who are inoperable or at high surgical risk 1, 3

The European Society of Cardiology recommends that the severity of secondary MR should be reassessed after optimized medical treatment before deciding on intervention 2
The European Society of Cardiology suggests that cardiac resynchronization therapy should be considered in appropriate candidates as it may reduce MR severity through increased closing force and resynchronization of papillary muscles 1

The European Society of Cardiology recommends that patients with moderate MR should have clinical evaluation every 6-12 months with annual echocardiography 3
The European Society of Cardiology suggests that patients with severe MR should have clinical evaluation every 6 months with annual echocardiography 3

The American College of Cardiology suggests that delaying surgical intervention until symptoms become severe or left ventricular dysfunction occurs can lead to worse outcomes 3
The American College of Cardiology recommends that failing to recognize the dynamic nature of secondary MR can lead to inappropriate management decisions 4