32 HOW TO TREAT: MITRAL REGURGITATION
32 HOW TO TREAT: MITRAL REGURGITATION
12 DECEMBER 2025 ausdoc. com. au
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Figure 11. Transoesophageal images. A. Transoesophageal doppler images showing restricted posterior leaflet and large atrium. B. Transoesophageal doppler images showing severe secondary mitral regurgitation from a restricted posterior leaflet and large atrium. C. 3D transoesophageal images showing cleft like defect in the posterior leaflet of mitral valve. D. 3D transoesophageal doppler images showing severe secondary mitral regurgitation due to restricted posterior leaflet and large atrium.
How to Treat Quiz.
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1. Which THREE statements regarding MR are correct? a It is the most common valvular heart disease in Western countries. b MR is defined as backward flow of blood from the left ventricle into the left atrium during diastole. c Untreated, the disease can lead to heart failure and death. d The US prevalence is greater than 10 % in those older than 75 years.
2. Which TWO may cause primary MR? a Ventricular dilatation. b Rheumatic heart disease. c Endocarditis. d Chronic atrial fibrillation.
3. Which THREE statements regarding MR are correct? a A recognised cause of MR in the young population is mitral annular calcification. b Rheumatic heart disease is a common cause of primary MR in developing countries. c Primary MR is defined as a structural abnormality in any component of the MV apparatus causing MV leak. d Secondary MR is defined as disease of the left atrium or ventricle that interferes with the integrity of the MV apparatus thus causing a leak in the MV.
4. Which THREE may be features of MR? a Exertional shortness of breath. b Some patients may be asymptomatic. c Systemic hypertension. d Fatigue and palpitations in severe MR.
5. Which TWO may be present on examination in MR? a Secondary MR murmurs, generally best heard at the right sternal border. b S3 plus a short diastolic murmur in significant primary MR. c Murmurs from the posterior leaflet generally directed towards the axilla. d A displaced apex beat, loud systolic murmur and cardiomegaly.
6. Which THREE statements regarding the investigation of MR are correct? a TTE is the initial assessment, given its non-invasive nature and easy availability. b TOE is mostly needed for a full assessment of MR. c Other useful modalities include cardiac MRI and right and left heart catheterisation. d Cardiac MR is generally less accurate and reproducible for quantitating MR volume, LV volume and LV ejection fraction.
7. Which TWO statements regarding the management of primary MR are correct? a Diuretics and inotropic agents may be indicated in acute MR. b Medical therapy has no role in acute MR. c Patients with MR and reduced LVEF require guideline directed heart failure therapy only. d There is no evidence to support the use of medical therapy in chronic stable MR and preserved LVEF.
8. Which THREE statements regarding intervention in primary MR are correct? a Intervention is indicated in all asymptomatic patients with severe MR. b Valve replacement is associated with a greater life expectancy than valve repair. c When intervention is indicated,
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MITRAL REGURGITATION
surgery remains the first line of therapy. d Percutaneous MV edgeto-edge repair is safe and effective in patients with primary MR and a prohibitive surgical risk.
9. Which TWO statements regarding the management of secondary MR are correct? a Treatment focuses on the mechanism of the MR. b Guideline-directed medical therapy in patients with heart failure and secondary MR improves mortality and quality of life. c Consider intervention before guideline-directed medical therapy. d Given the homogenous aetiology, outcomes post intervention are comparable.
10. Which THREE statements regarding the intervention in secondary MR are correct? a TEER is not recommended in secondary MR. b Decisions for intervention are based on the recommendations of a multidisciplinary heart team. c Consider mitral valve repair or replacement with bypass surgery in functional MR associated with coronary artery disease. d Evidence for surgery in isolated secondary MR is limited. of the posterior leaflet( see figure 11). The aetiology is thought to be mixed degenerative and functional, but the small cleft makes the transcatheter edge-to-edge technique challenging.
His right heart catheterisation shows normal pulmonary pressures, and his left heart catheterisation does not show any significant coronary artery disease. Lung function tests are performed, given his history of lobectomy and smoking, and these show severely reduced lung capacity. Blood tests show a creatinine that is at his baseline level, with a haemoglobin at the upper levels of normal. There are no significant abnormalities in the remaining blood work.
Trevor is referred to the heart team. Given his age, comorbidities( especially the reduced lung capacity from smoking and previous surgery), he is deemed unsuitable for cardiac surgery. His TOE is also reviewed to assess for anatomical suitability.
The mixed nature of the aetiology, and the cleft in the posterior mitral leaflet, render Trevor anatomically unsuitable for percutaneous mitral edge-to-edge repair. The consensus from the heart team meeting is to optimise his medical therapy and refer him for a trial based on new MV devices.
CONCLUSION
MITRAL valve disease is a common disease that requires accurate and detailed assessment. The mitral valve apparatus is very complex; all components, either in isolation or combination, may cause MR.
Thus, a detailed examination is important for decision making and guiding therapeutic options. Echocardiogram, both transthoracic and transesophageal, remains the cornerstone of evaluation of MV.
When intervention is required, surgery is the first-line therapy, but transcatheter options are viable in high-risk surgical patients. Early referral to specialised centres is essential for best outcomes.
A comprehensive history-taking coupled with a routine heart auscultation by GPs can play a pivotal role in early diagnosis and timely referral to specialised centres, ensuring optimal patient outcomes.
RESOURCES
• 2025 ESC / EACTS Guidelines for the management of valvular heart disease Developed by the task force for the management of valvular heart disease of the European Society of Cardiology( ESC) and the European Association for Cardio-Thoracic Surgery( EACTS) European Heart Journal( 2025) 46, 4635 – 4736 bit. ly / 4rs2rMR
• Otto CM, et al. 2020 ACC / AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology / American Heart Association Joint Committee on Clinical Practice Guidelines. Circ 2021; 143: e72 – e227 bit. ly / 3Tgy9NU
References Available on request from howtotreat @ adg. com. au