Following the Outpatient with Severe Mitral Regurgitation Marilyn Weigner MD RIACC 9/02

Mitral Regurgitation Potentially surgical: moderate to severe or severe mitral regurgitation Probably not surgical: mild or mild to moderate mitral regurgitation

How closely should I follow a patient with severe mitral regurgitation? Should the specific mitral valve anatomy influence timing of intervention? Are medications (ACE inhibitors/ beta blockers) useful in these patients? When should I refer to a cardiologist? Is it “too late”?

The patient is a 44 year old man with mitral valve prolapse and severe mitral regurgitation. He has been followed with office visits and serial echocardiograms. He now complains of new onset dyspnea and fatigue with a activities which had previously been easy for him. On exam: bp 120/85 hr 70 bpm jvp flat Cardiac: RRR loud holosystolic murmur at apex Lungs: clear Extremities: normal

Normal LV Size and function (EF 60%) Mitral leaflet prolapse and severe mitral regurgitation PA pressure estimated at 50 mmHg (elevated) Enlarged left atria

Management? a) Start captopril and lasix and follow the patient closely b) Repeat echo and exam in 6 months c) Suggest a surgical consult for mitral valve replacement (he is young and the St Jude valves last a long time) d) Refer for cardiac cath (cath is a better test than echo) e) Suggest surgical consult for mitral valve repair

ACC Guidelines :

Symptoms: Dyspnea and or fatigue Anatomy: Prolapse/Flail can often be repaired The left ventricle: Dysfunction/Enlargement Pulmonary artery pressure: elevation is sign of decompensation Rhythm: atrial fibrillation

Survival is better amongst patients who underwent repair

Reoperation rates slightly lower in patients who had repair

How should I follow a patient with asymptomatic severe mitral regurgitation? Patient with potentially surgical mitral regurgitation: -exam every 6 months and serial echocardiography looking for any signs of deterioration Does the specifics of mitral valve anatomy matter? Yes. Patients who have severe mitral regurgitation and mitral valve prolapse/flail leaftlets require closest follow-up because the “threshold” for surgical intervention should be lower

Are any medications helpful? In general, patients with severe mitral regurgitation should probably not be treated with medications— instead, follow closely for indications that it is time for surgical intervention No real “evidence-based” role for ace inhibitors or beta blockers for isolated mitral regurgitation When should I refer to a cardiologist? Consider cardiology input on any patient with potentially surgical mitral regurgitaion---help choose the “window” of opportunity for intervention---- it can get to be “too late”………

Patient with severe mitral regurgitation now with left ventricular dysfunction

Severe mitral regurgitation with left ventricular dysfunction