The patient is a 77-year-old female with hypertension, diabetes mellitus, dyslipidemia, pulmonary hypertension, medically managed coronary artery disease within the left circumflex coronary territory, and severe mitral regurgitation. She also has normal pressure hydrocephalus for which a VP shunt was placed. The patient was recently admitted for acute decompensated heart failure and has experienced several months of progressive exertion dyspnea. She is referred for management of mitral regurgitation.
A transthoracic echocardiogram reveals preserved LV systolic function with an LVEF 65% and mild inferolateral wall motion abnormalities that are unchanged compared to prior studies. Right ventricular size and function are normal. The left atrium is dilated with an indexed volume of 54.7 ml/m2. The aortic valve leaflets are mildly thickened with no evidence of stenosis or regurgitation. The mitral valve leaflets are mildly thickened. Increased mitral flow velocities are detected with a mean mitral valve gradient of 3 mmHg. The mid portion of the anterior mitral leaflet is flail (A2). There is severe mitral regurgitation with an eccentric posteriorly directed jet and systolic flow reversal detected in the pulmonary veins that was not noted on prior studies. There is mild tricuspid regurgitation. Estimated right ventricular systolic pressure is 65 mmHg. Systemic blood pressure at the time was 125/76 mmHg.
A transesophageal echocardiogram confirms these observations and further reveals a ruptured chordae tendineae to the mid anterior mitral leaflet, a flail gap of 5 mm, and a flail width of 10 mm. The mitral valve area is measured at 5.3 cm2 by planimetry.
A non-contrast chest CT reveals coarse calcification of the aortic root at the origin of the coronary arteries and a thin rim of calcification in the ascending aorta. Coarse noncontinuous calcification is noted within the aortic arch extending into the origin of the great vessels and the descending thoracic aorta. VP shunt tubing is noted in the upper right chest wall, crossing the midline to the lower left chest wall and entering the left upper quadrant.
What is the best treatment strategy for this patient's mitral regurgitation?
The correct answer is: D. Transcatheter mitral valve edge-to-edge repair
Choice A is incorrect.
Based on the ACC/AHA Guidelines for the Management of Valvular Heart Disease, goal-directed medical therapy is reasonable for patients with reduced left ventricular ejection fraction and severe primary mitral regurgitation when valve repair is not feasible or needs to be delayed. In patients with preserved left ventricular systolic function, vasodilators are indicated for hypertensive patients. Here, the patient is normotensive with preserved LV systolic function. GDMT is therefore not indicated.1,2
Choice B is incorrect.
Coronary artery bypass surgery with mitral valve repair would routinely be the treatment of choice for a patient with symptomatic coronary artery disease and primary (degenerative) mitral regurgitation, irrespective of LV systolic function. However, our patient has a porcelain aorta and a VP shunt that crosses the sternum, placing the patient at prohibitive risk for surgical intervention. In such patients, transcatheter mitral valve edge-to-edge repair is the recommended strategy.1,2
Choice C is incorrect.
In patients with severe secondary, ischemic mitral regurgitation, coronary revascularization may lessen the severity of mitral regurgitation. However, this patient has primary mitral regurgitation due to a ruptured chordae tendineae. While coronary revascularization may be warranted in the presence of ischemic symptoms, PCI will not modify or treat the mitral regurgitation.1
Choice D is correct.
Transcatheter mitral valve edge-to-edge repair (TEER) is the preferred strategy for symptomatic patients with severe primary MR that are at high or prohibitive risk for surgical mitral valve repair.1,2 While TEER was less effective than surgery in reducing the severity of MR within the EVEREST II Trial, it possessed superior safety and comparable and durable improvements in clinical symptoms and functional capacity.3,4 Furthermore, this patient's anatomy (segment 2 lesion with flail gap <10 mm, flail width <15 mm, mitral valve area >4 cm2), mean MV gradient <- 4mmHg) is ideal for TEER.2
Choice E is incorrect.
The patient has treatable cardiac lesions without other end-stage organ failure or severe limitation to her functional status or anticipated longevity. Palliative care would therefore not be recommended based on her cardiac status.
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Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017 Jun 20;135(25):e1159-e1195.
Bonow RO, O'Gara PT, Adams DH, et al. 2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2020 May 5;75(17):2236-2270.
Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011;364:1395-1406.
Feldman T, Kar S, Elmariah S, et al. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-year results of EVEREST II. J Am Coll Cardiol 2015;66(25):2844-54.