Timing Intervention in Asymptomatic Mitral Regurgitation

A 76-year-old male presents for a second opinion about treatment of his mitral regurgitation. He was initially diagnosed with mitral valve prolapse and mitral regurgitation (MR) 15 to 20 years ago and has been followed closely. The most recent echocardiogram, performed by his cardiologist, demonstrated an ejection fraction of 65% with severe MR and no other significant valve disease. Pulmonary function tests done the same day demonstrated an FEV1 of 1.90 L with a volume of 83.4%. He states that for the last 20 years he gets out of breath if he tries to run for a bus. Outside of that, he can function as a musician, travel, and lift his equipment without any impairment to his physical activity. There is no orthopnea, paroxysmal nocturnal dyspnea, or lower extremity edema. His past medical history is otherwise significant for stage III liver cancer, which has responded to chemotherapy and radiation with no evidence of recurrent disease. His cardiologist recommended he go forward and should consider intervention on his mitral valve.

On examination, his blood pressure is 178/90 mmHg with a heart rate of 68 bpm. His height = 64 inches, weight = 142 lbs (BSA = 1.69 cm2). He appears well and is in no apparent distress. His lungs are clear bilaterally. Cardiac exam reveals a normal S1, S2 with a regular rate and rhythm, and a 4/6 murmur at the apex radiating to the axilla. There is no edema. His 5-meter walk time in the office is 5 seconds.

Transthoracic Echocardiogram reveals a left ventricular end-diastolic (LVED) and end-systolic (LVES) diameters of 5.7 cm and 3.2 cm respectively, left atrial volume = 60 ml/m2, LF ejection fraction (LVEF) = 67%, relative wall thickness of 0.32 (normal), LV mass index = 120 gm/m2 (increased). There is bileaflet prolapse of the mitral valve with ruptured chordae to the P1-P2 scallops with associated flail leaflet. There are multiple regurgitant jets. One jet is posteriorly directed associated with anterior leaflet prolapse. Another jet is anterior/medially directed associated with the posterior flail leaflet. By volumetric Doppler methods, the total diastolic stroke volume = 160 cc with regurgitant volume calculated as 85 cc (regurgitant fraction = 53%) with effective regurgitant orifice area = 49 mm2.

Laboratory tests reveal a normal complete blood count, biochemistry profile and NT-ProBNP = 111.2 pg/mL.

What would your recommendation for this patient be?

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