Following the Outpatient with Severe

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Following the Outpatient with Severe Mitral
Regurgitation
Marilyn Weigner MD RIACC 9/02
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Mitral Regurgitation
Potentially surgical moderate to severe
or severe mitral regurgitation
Probably not surgical mild or mild to
moderate mitral regurgitation
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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?
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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
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Normal LV Size and function (EF 60)
Mitral leaflet prolapse and severe mitral
regurgitation PA pressure estimated at 50 mmHg
(elevated) Enlarged left atria
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• 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

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ACC Guidelines www.acc.org
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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
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Survival is better amongst patients who
underwent repair
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Reoperation rates slightly lower in patients who
had repair
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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
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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
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Patient with severe mitral regurgitation now with
left ventricular dysfunction
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Severe mitral regurgitation with left
ventricular dysfunction