A 62-Year-Old With History of Mitral Valve Prolapse and Regurgitation

The patient is a 62-year-old with a history of mitral valve prolapse and regurgitation (MR). The patient has no symptoms of chest pain or shortness of breath. The patient had been very active until 8 months ago, jogging on a treadmill daily for 30 minutes at 5.0 mph, but after sustaining a knee injury has not been able to exercise. The most physical activity the patient can presently do is walking up one flight of stairs.

PMHx: mitral valve prolapse, hypercholesterolemia, hypertension, normal renal function

Medications: simvastatin 20 mg, lisinopril 20 mg

PE: BP- 120/76 mmHg, pulse- 70 regular, RR-12
Heart: RRR with 3/6 holosystolic blowing murmur hear best at the apex with radiation to axilla. No RV heave. JVP- normal
Lungs: Clear
Extremities: no edema
ECG: normal sinus rhythm

Laboratory data (6 months ago):  BNP 80 pg/ml
Echocardiogram (6 months ago): Bilateral mitral valve  prolapse with severe MR, effective regurgitant orifice area (EROA = 0.42 cm2),  ejection fraction 65 %, left ventricular end systolic dimension (LVESD) 32 mm, systolic pulmonary artery pressure (SPAP) 25 mmHg,

Laboratory data (presently): BNP 170 pg/ml
Echocardiogram (presently): EROA = 0.44 cm2, ejection fraction 65%, LVESD 36 mmHg, SPAP 40 mmHg
Tranesophageal Echocardiogram confirms severe MR and demonstrates prolapse of both leaflets with central MR

An experienced cardiothoracic surgeon in mitral valve repair has reviewed that case and describes the case as moderately complex with a estimated 60-70% chance for repair.

What would you recommend as the most appropriate next step in this patient’s management?

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