MKSAP: 72-year-old man with a holosystolic murmur

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 72-year-old man is evaluated during a routine examination. He has no symptoms or significant medical history. He is active and exercises regularly. He does not take any medications.

On physical examination, blood pressure is 135/70 mm Hg, pulse rate is 82/min, and respiration rate is 17/min. Cardiac examination reveals a grade 3/6 apical holosystolic murmur.

Echocardiogram shows severe mitral regurgitation and a left ventricular ejection fraction of 45% without evidence of regional wall motion abnormalities.

Which of the following is the most appropriate management?

A. Vasodilator therapy
B. Percutaneous mitral balloon valvuloplasty
C. Repeat echocardiogram in 6 months
D. Surgical mitral valve repair

MKSAP Answer and Critique

The correct answer is D. Surgical mitral valve repair.

Mitral valve repair is the most appropriate option for this patient with asymptomatic severe mitral regurgitation and moderate left ventricular (LV) dysfunction. Surgery is indicated for patients with symptomatic acute severe mitral regurgitation, those with symptomatic chronic severe mitral regurgitation with LV ejection fraction greater than 30%, and asymptomatic patients with chronic severe mitral regurgitation and mild to moderate LV dysfunction (ejection fraction of 30%-60% and/or LV end-systolic dimension ≥40 mm). Mitral valve repair is the operation of choice when the valve is suitable for repair and appropriate surgical skill is available and is recommended for most patients. Mitral valve replacement, especially with chordal preservation, is appropriate for patients with severe mitral regurgitation in whom the valve is not repairable or a less than optimal result would be obtained. Recently, a percutaneously placed mitral valve clip has been introduced that is placed to better approximate the edges of the anterior and posterior leaflets of the valve and may be a therapeutic option in patients who are at a prohibitive risk for mitral valve surgery.

Vasodilator therapy, such as with ACE inhibitors or angiotensin receptor blockers, has not been shown to improve outcomes in patients with severe mitral regurgitation who are asymptomatic. Additionally, vasodilator therapy may mask the development of more severe left ventricular dysfunction due to regurgitant volume. Therefore, these agents should not be used as a substitute therapy for surgery when the patient is thought to be a surgical candidate.

Mitral balloon valvuloplasty or valvotomy is indicated for patients with severe mitral stenosis in whom there is a reasonable likelihood of success and in whom there are no contraindications (such as moderate to severe mitral regurgitation or left atrial thrombus). This patient has severe mitral regurgitation, and repair, not valvotomy, is indicated.

Serial echocardiography may be helpful in follow-up of the asymptomatic patient in whom worsening of LV systolic function or increase in chamber size may help facilitate decision for surgery. This patient’s LV function is compromised and intervention is indicated.

Key Point

  • Mitral valve repair is the operation of choice for severe mitral regurgitation when the valve is suitable for repair.

This content is excerpted from MKSAP 17 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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