Treatment Options for Degenerative Mitral Regurgitation
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?