Mitral regurgitation — structured written assessment

Scenario 1 (10 marks, suggested 15 minutes)

Practice scenario (fictional patient). A 58-year-old teacher is referred after a murmur is heard at a routine check. She plays competitive hockey and reports no symptoms. ECG shows sinus rhythm. Echocardiography: severe primary MR from a flail posterior leaflet segment; LVEF 62%; LVESD 34 mm; LVESDi 17 mm/m²; LA volume index 52 mL/m²; resting SPAP 32 mmHg; trivial TR. Her surgical risk is low and the valve looks repairable. Measurements follow the ESC/EACTS 2025 and ACC/AHA 2020 definitions.^[1][2]

1. Classify her using the ACC/AHA 2020 stages and state whether the ESC/EACTS 2025 markers of LV dysfunction are present. (3 marks)
2. List the findings that would give her an ESC/EACTS 2025 indication for surgery at a later review, with class and level. (3 marks)
3. Outline the follow-up plan, and explain how ACC/AHA 2020 frames early repair for a patient like her. (2 marks)
4. Quote long-term evidence on early surgery in asymptomatic severe degenerative MR. (2 marks)

Model answers

1. She has asymptomatic severe primary MR with LVEF above 60% and LVESD below 40 mm, which is ACC/AHA 2020 stage C1.^[2] ESC/EACTS 2025 defines LV dysfunction as LVEF 60% or less, LVESD 40 mm or more, or LVESDi 20 mm/m² or more. She meets none. She is also below the lower women-specific cut-offs that ESC/EACTS 2025 cites evidence for considering (LVESD 36 mm; indexed LVESD 1.8 cm/m²).^[1]

2. LV dysfunction while still asymptomatic: LVESD 40 mm or more, LVESDi 20 mm/m² or more, or LVEF 60% or less, where MV surgery is recommended (Class I, level B).^[1] In an asymptomatic patient without LV dysfunction, surgical repair is recommended in a low-risk patient when a durable result is likely, if at least three criteria are present (I B).^[1] The criteria are AF, resting SPAP above 50 mmHg, LA dilatation (LAVI 60 mL/m² or more or LA diameter 55 mm or more), and secondary TR of at least moderate grade.^[1] In asymptomatic patients without LV dysfunction, MV surgery should be considered with either resting SPAP above 50 mmHg or AF secondary to MR (IIa B).^[1] In low-risk asymptomatic patients without LV dysfunction, surgical repair should be considered with significant LA dilatation (LAVI 60 mL/m² or more or LA diameter 55 mm or more), in a Heart Valve Centre when a durable repair is likely (IIa B).^[1] If symptoms develop, MV surgery is recommended in symptomatic severe primary MR in patients considered operable by the Heart Team (Class I, level B).^[1] ACC/AHA 2020 states that symptom onset is an indication for prompt mitral valve surgery.^[2]

3. Playing hockey is a report; her exercise capacity has not been documented. A formal treadmill test can establish true exercise tolerance and form a baseline.^[2] With no intervention criteria met and documented preserved exercise capacity, ESC/EACTS 2025 advises clinical and echocardiographic review twice a year, ideally in a Heart Valve Clinic.^[1] ACC/AHA 2020 describes early repair before triggers appear as an alternative strategy, which needs a high degree of certainty of a durable repair and treatment in a Comprehensive Valve Center. In excellent hands, patients with severe MR from flail leaflets who undergo early operation have less HF and lower mortality than with watchful waiting.^[2]

4. In 1063 asymptomatic patients with severe degenerative MR and preserved LV function, followed for a median of 12 years, cardiovascular death was 1.5% with early surgery vs 10.4% with conventional care (HR 0.17). All-cause death HR was 0.72; there were no operative deaths and repair succeeded in 97%.^[4]

Scenario 2 (10 marks, suggested 15 minutes)

Practice scenario (fictional patient). A 67-year-old man with ischaemic cardiomyopathy has his third HF admission in 6 months. He takes an ARNI, a beta-blocker, an MRA and an SGLT2 inhibitor; a CRT device is in situ. Echocardiography on admission, while congested, reports severe secondary MR. Drug classes follow the ESC/EACTS 2025 description of GDMT.^[1]

1. What must happen before a valve-directed decision? (3 marks)
2. After optimisation he is haemodynamically stable, euvolaemic and normotensive. Severe secondary MR persists: NYHA class III, LVEF 33%, LVESD 62 mm, SPAP 55 mmHg, no severe RV dysfunction, no stage D (advanced) HF, no CAD needing revascularisation, no severe aortic or tricuspid valve disease, no hypertrophic, restrictive or infiltrative cardiomyopathy, anatomy suitable for TEER. State the recommendation and its basis. (4 marks)
3. A colleague cites MITRA-FR to argue against TEER. Respond. (3 marks)

Model answers

1. Re-grade the MR after medical therapy is optimised, with the patient euvolaemic and normotensive.^[1] GDMT at maximum tolerated doses must be up-titrated rapidly, within 6 weeks; in about 40% of patients with ventricular SMR, SMR severity improves after 1–3 months of optimised GDMT.^[1] The ESC/EACTS 2025 text (no recommendation-table row) adds that CRT should be considered before an MV intervention if HF criteria are met (LVEF 35% or less and wide QRS).^[1] A multidisciplinary Heart Team including HF specialists decides; intervention is based on NYHA II–IV symptoms that persist despite adequate GDMT and CRT, if indicated.^[1][9]

2. He meets every ESC/EACTS 2025 Table 7 criterion. Clinically: NYHA II or more, HF hospitalisation within the past year, no stage D HF and no CAD needing revascularisation. On echo: LVEF 20–50%, LVESD 70 mm or less, SPAP 70 mmHg or less and suitable anatomy. None of the remaining exclusions apply: severe RV dysfunction, severe aortic or tricuspid disease, or hypertrophic, restrictive or infiltrative cardiomyopathy.^[1] The 2026 ESC HF guideline recommends TEER (Class I, level B1) in haemodynamically stable, symptomatic HFrEF patients with persistent severe secondary MR despite optimised therapy and CRT if indicated. They must fulfil its Table 19 criteria, which mirror ESC/EACTS Table 7 and add optimised therapy as a criterion.^[3][1] The aim is to reduce HF hospitalisation and improve quality of life.^[3] ESC/EACTS 2025 recommends TEER in haemodynamically stable, symptomatic patients with LVEF below 50% and persistent severe ventricular SMR without concomitant CAD, despite optimised GDMT and CRT (if indicated), who fulfil its specific clinical and echo criteria (Class I, level A).^[1] ACC/AHA 2020 states that mitral TEER is indicated to improve symptoms and prolong life in a select subset with chronic severe secondary MR, LV systolic dysfunction and persistent severe symptoms on optimal GDMT.^[1][2]

3. COAPT reported all HF hospitalisations within 24 months of 35.8% vs 67.9% per patient-year (HR 0.53) and death within 24 months of 29.1% vs 46.1% (HR 0.62).^[5] The benefit persisted through 5 years (HF hospitalisation HR 0.53; death HR 0.72).^[8] MITRA-FR, in severe secondary MR, found no significant difference in death from any cause or unplanned HF hospitalisation at 12 months (54.6% vs 51.3%).^[6] ACC/AHA 2020 notes MITRA-FR enrolled larger ventricles with less severe MR (mean ERO 0.31 vs 0.41 cm²). Grayburn describes that MR as proportionate to LV dilatation.^[2][7] His profile sits inside the COAPT enrolment criteria, which ACC/AHA 2020 calls the current standard selection criteria for TEER in secondary MR.^[2]