30 HOW TO TREAT: MITRAL REGURGITATION
30 HOW TO TREAT: MITRAL REGURGITATION
12 DECEMBER 2025 ausdoc. com. au
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size alone( that is, a bigger ventricle means more advanced cardiomyopathy; this implies dual pathology, which means correcting the MR may not result in improvement, or the damage is irreversible). 30
The percentage of disproportionate MR was greater in the COAPT
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J. Heuser / CC BY / bit. ly / 4boQzTI |
Figure 7. Echocardiogram of severe mitral regurgitation. |
J. Heuser / CC BY / bit. ly / 42smGOe |
trail compared with the MITRA-FR |
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trial. Thus, selecting the right patient |
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for the right procedure at the right |
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time is a complex and nuanced process |
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that highlights the need for |
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early referral to specialist centres. |
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CASE STUDIES
Case study one
FELIX, a 74-year-old male, has been feeling progressively short of breath over the past three months. This started when he was diagnosed with COVID-19 four months ago. Since then, he has not felt“ normal”. Six months ago, he was able to walk for more than 30 minutes. He can currently only walk 100 meters before he must stop to catch his breath. There is no shortness of breath at rest. Felix also gets occasional self-limiting palpitations that last a few minutes, but he does not have either chest pain or other cardiac symptoms.
He has a history of ischaemic heart disease( with a previous coronary artery angioplasty with a stent in 2018), hypertension, dyslipidaemia and right knee osteoarthritis. Felix lives with his wife at home, is independent with all activities of daily living and has no gait aids. He is a non-smoker and drinks minimal alcohol.
On examination, he has a soft pansystolic murmur to the left of the sternal border in the 5th intercostal space, which radiates to the axilla. There are no signs of heart failure, and he appears euvolemic.
Laboratory investigations show a normal haemoglobin, and his ECG is unremarkable. A chest X-ray does not show any significant changes that would explain his shortness of breath. A transthoracic echocardiogram shows severe MR. Felix’ s left atrium is mildly dilated, and his right atrial size is within normal limits. His left ventricular function is preserved. There is no other significant valvular disease.
Felix is referred to a specialised centre with experience in the treatment of MV pathology. He undergoes further workup with a TOE, which shows mildly thickened mitral leaflets( see figure 9). Additional findings include restricted P2 leaflet motion and anterior leaflet prolapse. MR proximal isovelocity surface area( PISA) = 1.1cm, MR effective regurgitant orifice is 0.43cm( severe = more 0.4cm), and MR regurgitant volume is 77mL.
His left and right ventricular functions are normal with no other significant abnormalities, and pulmonary pressures are normal. Right heart catheterisation shows mildly elevated pulmonary pressures with normal peripheral vascular resistance. Left heart catheterisation shows mild to moderate disease in all the main arteries with severe disease in a small calibre left anterior descending diagonal branch.
Felix’ s case is discussed in the heart team meeting, and given that he has no significant past medical history that precluded him from surgery, he is referred for a surgical MV repair.
Figure 6. Echocardiogram of severe mitral regurgitation.
Follow-up
Figure 8. Management of patients with primary mitral regurgitation.
Case study two
Anne, an 86-year-old female, presents to ED with acute decompensated heart failure requiring admission.
Her symptoms have progressed over the preceding few weeks. She
LVEF 60 % or less or LVESD 40mm or greater
No
High likelihood of durable repair, low surgical risk, and LA dilatation a
No
New onset of AF or SPAP greater than 50mm Hg
No
Yes
Yes
Surgical mitral valve repair
No
Yes
AF = atrial fibrillation; HF = heart failure; LA = left atrium / left atrial; LVEF = left ventricular ejection fraction; LVESD = left ventricular endsystolic diameter; SPAP = systolic pulmonary arterial pressure; TEER = transcatheter edge-to-edge repair. a
LA dilatation: volume index 60mL / m 2 or greater or diameter 55mm or greater at sinus rhythm. b
Extended heart failure treatment includes the following: cardiac resynchronisation therapy; ventricular assist devices; heart transplantation. Based on Vahanian A et al 2021 15 initially started to have shortness of breath only after walking long distances or doing a moderate amount of exercise. The symptoms progressed quickly to shortness of breath with shorter distances.
Before presenting to hospital, she
Symptoms
No
Surgery( repair whenever possible)
Yes
Inoperable or at high surgical risk
Operative risk judged by the heart team
Yes
TEER if anatomically suitable / extended HT treatment b
was waking up from sleep frequently with a feeling of suffocation and needed to use three pillows to be able to sleep for only few hours.
Her past medical history includes type 2 diabetes mellitus, chronic kidney disease, mild cognitive
High risk of futility
Palliative care
impairment and known severe MR. Despite her mild cognitive impairment, Anne manages to live alone in a unit that is close to her children. She does not use any walking aids, is a distant ex-smoker and does not drink alcohol.