Management of Severe Mitral Regurgitation

Initial Classification and Management

The European Society of Cardiology recommends surgery as the definitive treatment for severe mitral regurgitation, with specific indications determined by whether the MR is primary or secondary, symptom status, left ventricular function parameters, and surgical risk 1, 2
The American College of Cardiology suggests that primary MR results from intrinsic valve pathology, while secondary MR results from left ventricular dysfunction causing annular dilatation or papillary muscle displacement 3, 4

The European Society of Cardiology indicates that surgery is recommended for all symptomatic patients with severe primary MR and LVEF >30%, with mitral valve repair preferred over replacement when durable repair is technically feasible 1, 2
Early surgery (within 2 months of indication) is associated with better outcomes, as even mild symptoms indicate deleterious cardiac changes 5
The American College of Cardiology recommends considering surgery in asymptomatic patients with preserved LV function when new-onset atrial fibrillation develops, pulmonary hypertension is present, or flail leaflet with LVESD ≥40 mm 5

The European Society of Cardiology emphasizes that optimal guideline-directed medical therapy is mandatory as the first step for all patients with secondary MR, as severity is dynamic and changes with loading conditions, blood pressure, volume status, and heart rate 3, 4, 6
The American College of Cardiology suggests that surgery is indicated in patients with severe secondary MR undergoing CABG with LVEF >30%, and may be considered in patients who remain symptomatic despite optimal medical therapy, have LVEF >30%, and are at low surgical risk 3, 1, 2

The American College of Cardiology recommends considering TEER in patients with symptomatic severe primary MR who are at high or prohibitive surgical risk, as a Class IIb recommendation 7
TEER should be considered in patients with severe secondary MR who remain symptomatic despite optimal GDMT, have LVEF 20%-50%, and are at high surgical risk or inoperable, as a Class IIa-B recommendation 7

The European Society of Cardiology recommends immediate hemodynamic stabilization with nitrates and diuretics, and considers sodium nitroprusside, intra-aortic balloon pump, and inotropic agents as needed 5
Papillary muscle rupture is a surgical emergency requiring urgent intervention 6

The European Society of Cardiology recommends clinical evaluation every 6-12 months with annual echocardiography for moderate MR, and every 6 months with annual echocardiography for severe MR 4

The American College of Cardiology advises against using vasodilators chronically in primary MR with preserved LV function, delaying surgery in primary MR until severe symptoms or significant LV dysfunction develops, and failing to recognize the dynamic nature of secondary MR 5, 4, 6
The European Society of Cardiology emphasizes the importance of optimizing GDMT including CRT if indicated before considering intervention in secondary MR, and referring patients to experienced centers for mitral valve repair 3, 4, 6