Andrew's Journal

 Factors determining timing of surgery for degenerative mitral regurgitation in the current American College of Cardiology and American Heart Association guidelines include symptoms, left ventricular (LV) ejection fraction (EF), LV end-systolic dimension (LV ESD), atrial fibrillation, and pulmonary hypertension1. All patients who have any symptoms and moderate or severe mitral regurgitation should be referred for surgical treatment. It is preferable to operate on patients early in their symptomatic course, as long term survival following mitral valve repair is compromised in patients with New York Heart Association Class III or IV symptoms (see Figure 1)2. Patients with lesser degrees of regurgitation in the presence of symptoms will often be found to have increased mitral regurgitation, or inadequate increase in ejection fraction, on stress echocardiography and should also be referred for surgical consideration3. Asymptomatic patients with left ventricular dilatation (LV end systolic diameter more than 45 mm), decreased Ejection Fraction (<60%), atrial fibrillation or pulmonary hypertension (PA systolic pressure > 50 mm Hg at rest or > 60 mm Hg with exercise) should also be considered for elective mitral valve surgery. When following patients with asymptomatic moderate to severe mitral regurgitation, one should pay particular attention to serial ejection fraction, as a drop to <60% confers poorer long term survival even with successful mitral valve repair (Figure 2)4.