MITRAL VALVE REPAIR

SUGISMAN

Pusat Jantung Nasional Harapan Kita

Jakarta 2007

INTRODUCTION

Mitral valve repair is the procedure of choice to

treat mitral valve dysfunction of all etiologies
Advantages of mitral valve repair over mitral
valve replacement include improved long-term
survival, better preservation of left ventricular
function, and greater freedom from
endocarditis, thromboembolism, and
anticoagulant-related hemorrhage
Mitral valve repair has become reproducible
and widely disseminated

Normal Valve Function

Maintain forward
flow and prevent
reversal of flow.
Valves open and
close in response to
pressure differences
(gradients) between
cardiac chambers.

Mitral Valve Competence:

Integrated function
of several anatomic
elements

Posterior LA wall
Anterior & Posterior
valve leaflets
Chordae tendineae
Papillary muscles
Left ventricular wall
where the papillary
muscles attach

SURGICAL ANATOMY OF THE

MITRAL VALVE

Leaflets
Annulus
Chordae
Tendineae
Papillary
Muscles
Left Ventricle

Abnormal Valve Function

Valve Stenosis

Valve Regurgitation, Insufficiency, Incompetence

Obstruction to valve flow during that phase of the cardiac

cycle when the valve is normally open.
Hemodynamic hallmark -pressure gradient
Inadequate valve closure--- back leakage

A single valve can be both stenotic and regurgitant;

but both lesions cannot be severe!!
Combinations of valve lesions can coexist

Single disease process

Different disease processes
One valve lesion may cause another
Certain combinations are particularly burdensome (AS & MR)

Mitral Valve Disease:

Etiology

Mitral Stenosis

Rheumatic - 99.9%!!!

Congenital
Prosthetic valve stenosis
Mitral Annular
Calcification
Left Atrial Myxoma

Chronic Mitral
Regurgitation

Acute Mitral Regurgitation

Infective endocarditis
Ischemic Heart disease

Mitral valve prolapse

Papillary ms rupture

Chordal rupture

Chest trauma

Ischemic Heart disease

Papillary ms dysfunction
Inferior & posterior MI

Mitral Valve prolapse

Infective endocarditis
Rheumatic
Prosthetic
Mitral annular
calcification
Cardiomyopathy

LV dilatation

Mitral RegurgitationPathophysiology

MR: Leakage of blood

into LA during systole
Compensatory
Mechanisms

Increase in SV (& EF)

Forward SV +
regurgitant volume
LV (LA) dilatation
Left Ventricular
Volume Overload
(LVVO)

Chronic Mitral Regurgitation LVVO

LVVO

LV dilatation
Eccentric hypertrophy

Increased LA
pressure
Pulmonary HTN
Dyspnea
Atrial arrhythmias
Low output state

Pathophysiology Acute vs
Chronic Mitral Regurgitation

Acute MR

Chronic MR

Normal (noncompliant) LA
Increase LA pressure
Acute Pulmonary Edema
Dilated, compliant LA
LA pressure normal or
slightly increased
Fatigue, low output state
Atrial arrhythmias- a. fib.

Most patients fall between

these two extremes!!

Ischemic Mitral
regurgitation

Caused by CAD,distinguished from

organic MV disease.
Valve leaflets and chordae appear
normal.
LV dysfunction
Three mechanisms:(1)ruptured PM,
(2)infarcted PM without rupture,(3)
functional regurgitation.

Mechanisms of ischemic
mitral regurgitation
Reversible ischemia
Transientleftventriculardilatation/dysfunction
Myocardial infarction
Rupturedpapillarymuscle
Infarctedbutunrupturedpapillarymuscle
Functional
Leftventriculardilatation/dysfunction
Annulardilatation
Leftventriculardilatation/dysfunctionand
annulardilatation

Functional ischemic mitral regurgitation

occurs when ventricular dilatation and
dysfunction cause leaflet tethering,
preventing normal leaflet coaptation

Mitral Stenosis
-Pathophysiology

Restriction of blood flow

from LA LV during
diastole.
Normal MVA 4-6cm2.

MV Pressure gradient
MV grad ~ MV flow//MVA.

Mild MS 2-4cm2.
Severe MS < 1.0cm2.

Flow = CO/DFP (diastolic

filling period).

As HR increases, diastole
shortens disproportionately
and MV gradient increases.

Mitral StenosisPathophysiology

MV gradient
Increase LA press
Pulmonary HTN
Passive
Reactive- 2nd
stenosis
RV Pressure Overload
RVH
RV failure
Tricuspid
regurgitation
Systemic
Congestion

Mitral Stenosis- Clinical Symptoms

Symptoms related to
severity of MVA reductionSymptoms unrelated to
severity of MS Atrial fibrillation
Systemic
thromboembolism
Symptoms due to
Pulmonary HTN and RV
failure Fatigue, low output
state
Peripheral edema and
hepato-splenomegaly

Mitral Valve Disease Echo

findings

Mitral Stenosis

Thickened, deformed MV
leaflets
2D MVA
Doppler Gradient
Associated RVH, PHTN,
TR,MR, LV function

Mitral Regurgitation

Determine etiology
leaflets, chordae, MVP, MI
Doppler severity of MR jet
LV function

Carpentiers functional
classification pathophysiological
triad :

Etiology (cause of the disease)

Valve lesion (result of etiology)
Valve dysfunction (result of the valve
lesion)

Type I : Normal leaflet motion ec annular

dilatation or leaflet perforation
Type II : Increase leaflet motion (leaflet
prolapse ec chordal elongation or rupture &
papillary muscle
Type IIIA : Restricted leaflet motion (systolic
& diastolic) ec leaflet
tickening/retraction,chordal
thickening/shortening or fusion &
commisural fusion
Type IIIB : restricted leaflet motion during
systolic ec LV enlarge with apical papillary
muscle displacement

Recommendation for MVr for Mitral Stenosis :

Pts with NYHA fc III-IV symptoms,moderate or

severe MS,and valve morphology favorable for
repair if percutaneous BMV is not available.
Pts with NYHA fc III-IV symptoms,moderate or
severe MS,and valve morphology favorable for
repair if a LA thrombus is present despite
anticoagulation.
Pts with NYHA fc III-IV symptoms,moderate or
severe MS,and a nonpliable or calcified valve
with the decision to proceed with either repair or
replacement made at the time of the operation.
Pts in NYHA fc I,moderate or severe MS,and valve
morphology favorable for repair who have had
recurrent episodes of embolic event on adequate
anticoagulation.
Pts with NYHA fc I-IV symptoms and mild MS.

Mitral valve evaluation :

Valve exploration begins with the TEE

evaluation.
Give information:what must be done to fix
the valve anatomy and mobility of the
leaflets,size of annulus,size and direction of
regurgitant jets.
Characteristic for certain valvular pathologies
and the planning of the operation.
TEE intraoperative:confirmation of a
successful repair

Valve Analysis

Preoperative and intraoperative echo define the

mechanism of mitral valve dysfunction before
the valve is visualized
The annulus is systematically evaluated for
dilatation and/or deformity
Leaflets and leaflet motion are examined next.
Nerve hooks are used to assess leaflet pliability
and to assess leaflet prolapse or restriction
The motion of each leaflet is classified as
normal (type I), prolapsed (type II), or restricted
(type III)

Lesions that produce MR with normal leaflet

motion include annular dilatation and leaflet
perforation
Lesions that produce regurgitation with
prolapse include chordal rupture, chordal
elongation, papillary muscle rupture, and
papillary muscle elongation
Lesions that produce regurgitation with
restricted leaflet motion include ventricular
dilatation and dysfunction and rheumatic
involvement of the subvalvular apparatus
the chordae are examined to evaluate length,
thickening, fusion, or rupture
Finally, the papillary muscles are assessed,
looking for elongation or rupture secondary to
infarction.

Valve Exposure :

Interatrial approach through

Waterston Groove
Horizontal Biatrial transseptal
Superior Biatrial Transseptal

Valve exposure

Excellent exposure
is key performing
successful MV
exploration and
repair
Superior-septal
incision

Right atriotomy is
across the atrial
appendage and
extends inferiorly
parallel to and near
the AV groove

The incision is
extended medially and
superiorly as well.
The LA is opened in
the fossa ovalis
superiorly and
vertically across the
atrial septum until it
join the RA incision.
Extends onto the
superior dome of the
LA and underneath the
ascending aorta.

Valve Repair in Type I

Dysfunction

Annular dilatation : annuloplasty

Leaflet perforation
endocarditisdebridementpatch
pericardium

Valve Repair in Type II

Dysfunction

Posterior leaflet Prolaps : quadrangular

resectionplication posterior
annulusdirect suture of the leaflet
Barlows diseasequadrangular
resectionsliding leaflet,P1 & P3
detachedcompression suture at post.
annulusgap closed interrupted
sutures

Anterior Leaflet Prolapse

Triangular Resection
Chordal Transfer : secondary position to the free
margin of anterior leaflet.
Chordal transposition : absence of normal
secondary chordae,marginal chordae of posterior
segment apposite to the prolapsed area
Artificial Chordoplasty:distance between the base
of PM & free margin leaflet. Gore-Tex suture.
PM Sliding Plasty: elongation of multiple chordae
from a PM
PM Shortening

Valve Repair in Type IIIA

Dysfunction

Correction achieved by treating each

type of lesion : Leaflet restriction :
chordal thickening,retraction,fusion.
ThickeningResection secondary
chordae,Fusionchordal
fenestration.Retractionpericardial
patch enlargement.

Valve Repair in Type IIIB

Ring annuloplasty

Annuloplasty

May be used as sole therapy or in conjunction

with other repair maneuvers to support the
reconstruction and reinforce the annulus as well
as prevent future annular dilatation.
For pure annular dilatation causing mitral
regurgitation an annuloplasty reducing the orifice
size alone may suffice. This serves to increase
leaflet free-edge coaptation.
A ring annuloplasty device provides staged
plication of the posterior annulus with selective
tailoring of more severely involved areas

The mitral annulus is

sized by measuring the
distance between the
fibrous trigones.
Sutures are horizontal
mattress. Although a
complete ring is
depicted in the figure,
we often will only
perform a posterior
annuloplasty and
cutout a portion of the
ring.

For pure annular dilatation as the etiology of

regurgitation, a complete ring is preferred.
This may be sized based on standard body
surface areas but generally requires a 27mm
to 29mm ring for an adult male and 25mm to
27mm ring for a typical adult female.

Posterior annuloplasty sutures may be placed

early in the valve assessment, which will aid
in exposure of the surgical field as well as
facilitate placement of subsequent sutures.

Cosgrove-Edwards
Annuloplasty Band

Carpentier-Edwards
Annuloplasty Ring

Open Commisurotomy

With rheumatic valvular disease, mitral

stenosis is caused by restricted leaflet
mobility. Partial fusion of the commissures
with a well-defined border between the
anterior and posterior leaflets is ideal.

The repair technique requires continued

observance of the chordal support
mechanism. With traction applied to the
major chords of the anterior leaflet near
the commisure, a furrow or dimple is
created where the leaflets should be
incised and separated.

Quadrangular resection

Most common situation seen in mitral regurgitation :

myxomatous degeneration. Prolapse of the middle scallop
of the posterior leaflet ec chordal rupture or chordal
elongation.
Combined with a posterior mitral annuloplasty is the best
way to handle this situation
This quadrangular resection is accomplished by first
locating the margins of the involved portion where the
chordae are of normal length and structure. A heavy silk tie
is passed around these chords to identify and gently retract
the section of the posterior leaflet that is not going to be
excised. The involved or prolapsed segment is then
excised.
Advancement flaps are generally then created by cutting
along the annulus of remaining posterior leaflet. This
creates a sliding plasty of the posterior annulus. The
annulus may then be selectively plicated at areas of severe
dilatation.

Ring annuloplasty sutures are then placed

along the posterior annulus.
The posterior leaflet is then reconstructed.
First, the free edges along the margin of
coaptation are identified. A 5-0
polypropylene suture is used to
reapproximates these two points.
From here, the same suture is run along the
body of the leaflet halves back towards the
base in a two-layer fashion. The two ends of
the suture are then placed through the
plicated posterior annulus.
The same suture, again, is used to attach the
leaflet to the posterior annulus in running
two-layer stitch.

This leaflet-sliding-plasty technique of creating

advancement flaps allows for removal of up to 50%
of the posterior leaflet.
The suture begins at the free margin of the leaflet
and both halves are run towards the annulus.
To reattach the leaflet, each half of the suture is then
run towards one commisure and back to the middle
completing a double suture line before any knot is
required.
Placing the posterior ring annuloplasty suture before
the leaflet reconstruction elevates the annulus into
the wound and improves exposure.
The annulus may be selectively plicated by focal
annuloplasty sutures before the leaflet is reattached.

Ruptured chordae to the middle scallop of the posterior

leaflet are identified

The middle scallop of the posterior leaflet is excised

(removed), incorporating all unsupported leaflet.

The annulus is plicated with 2 pledgetted sutures. The

leaflet edges are reapproximated with 5.0 braided
suture and

.and an annuloplasty is

placed

Triangular resection

Triangular Resection of the anterior leaflet is

may be used for torn chordae tendinae on the
anterior leaflet, generally of the central scallop.
With a redundant anterior leaflet, this technique
may also be helpful, a small wedge or triangle
of the anterior leaflet is excised.
To excise a wedge from the free edge of the
leaflet back to near the junction with the
annulus.(past)
Only excise a small triangle of the anterior
leaflet and generally do not extend the incision
beyond the mid-body of the leaflet.(now)

Primary Leaflet repair

Many of the above mentioned techniques are also

useful for repairing a hole in a mitral valve leaflet.
The defect in the leaflet may instead be patched
with autologous or homologous material.
autologous pericardium may be sewn as a patch
covering the hole
use allograft mitral valve tissue for such a repair.
This tissue is not specifically stored or procured
for this but may be used in conjunction with
allograft aortic valve replacement since the
anterior leaflet of the mitral valve usually remains
attached with the graft.

Chordae tendinae

SHORTENING: We discourage the use of chordal

shortening techniques in which a trench is created
in the papillary muscle a segment of the elongated
chord is buried within the muscle.

REPLACEMENT: Polytetrafluoroethylene (Gore-Tex)

can be used to create chordae tendinae in
circumstances of elongated or broken chords or
when additional chords are required to support the
free edge of a leaflet after repair techniques are
employed.
These chords are constructed by passing one of the
needles on a double-armed suture twice through the
tendinous portion of the papillary muscle that is
closest to the free margin of the desired leaflet.

Gor-Tex chord for correction of anterior

leaflet prolapse. Chordae may be constructed
from Gore-Tex sutures. Affixed to the head of
m.papillary with pledget.the loop is then attached
to the free edge of the unsupported anterior
leaflet,providing support.

TRANSFER

If a medial or paramedial chord is torn or

elongated from the anterior leaflet, a
corresponding opposing chord from the
posterior leaflet is transferred to the
anterior leaflet and the defect in the
posterior leaflet closed.
Chordae of proper length are borrowed
from the posterior leaflet and are
transposed to the anterior leaflet.

Chordal transfer to correct anterior leaflet

prolapse.Posterior leaflet chordae are
transferred to the unsupported free edge
of the anterior leaflet.The posterior leaflet
is repaired as after a quadrangular
resection

Posterior leaflet quadrangular resection. (Top)

After leaflet resection, the annulus is plicated
with one or two pledgeted sutures. (Bottom)
The leaflet edges are approximated, and an
annuloplasty completes the repair.

Sliding leaflet repair

to prevent SAM. (Top)
After leaflet
resection, the
posterior leaflet is
detached from the
annulus for a
distance of 1 to 2 cm
toward each
commissure. (Middle)
Annuloplasty sutures
are placed, and the
leaflet is reattached
to the annulus.
(Bottom) The leaflet
edges are
reapproximated, and
annuloplasty
completes the repair.

Chordal transfer from posterior to anterior

leaflet. In order to support a portion of anterior
leaflet with ruptured chordae, a segment of the
posterior leaflet with its attached chordae is
transferred to the anterior leaflet.

Chordal transfer from anterior leaflet. A

normal secondary chord is transferred from
the body to the free edge of the anterior
leaflet to correct prolapse caused by anterior
chordal rupture.

The Cleveland Clinic continues to perform the largest number

of valve procedures in the United States. In 2005, Cleveland
Clinic surgeons performed 1,603 primary valve operations and
572 valve reoperations.
Valve Procedure Volume

Despite the increasing complexity of the procedures, hospital mortality for

primary valve operations was only 1.5% in 2005.

Distribution of Primary Valve Procedures

Isolated Mitral Valve

Repair

In 2005, the Cleveland Clinic performed 305 isolated mitral valve repairs. Mortality
was 0.3%, compared with The Society of Thoracic Surgeons' (STS) benchmark of
1.1%.

Mitral Valve Repair vs.

Replacement

Cleveland Clinic surgeons performed 1,164 mitral valve procedures

in 2005; 69% were valve repairs.

Repair of Rheumatic Mitral Valve Incompetence: What Technique Should Be

Used ?
Nguyen Van Phan
The Heart Institute Hcm City, Ho Chi Minh, Vietnam
OBJECTIVES:Mitralvalverepairisthebestalternativetovalvereplacement.
METHODS:From1992to2003,1161casesofmitralinsufficiencywereoperatedbyreconstructivetechniqueintheHeartInstitute-HCM
city,Vietnam.Rheumaticfeverwasthemostcommoncauseofthedisease(86.8%)andfeasibilityofrepairinrheumaticvalveswas75%.The
meanagewas31+14.4ys;atrialfibrillation:54.1%;meancardio-thoracicratio:0.62+0.07andmorethan30%ofpatientswereoperatedin
NYHAIIIorIV.

RESULTS:Therewerethreespecificlesionsinrheumaticmitralvalveincompetence:(1)leafletretraction(lackofvalvulartissue):16.5%;(2)
distensionoffreeedge:14.8%;(3)chordalshorteningsyndrome:9.2%.
-Leafletextensionwithautologouspericardialpatchisthebestchoicetocorrectthelackofvalvulartissueinrheumaticvalve(176patients).
-Transpositionofchordaeandmarginalizationofchordaeispreferredforthetreatmentofanteriorleafletprolapse(252pts)
-Prostheticringwasnecessaryin96.2%ofpatients.
-Hospitalmortality:1.6%(19/1008).
-Assessmentofmitralregurgitationafteroperationshows80.3%excellent,17.4%moderateMIand2.3%severeMI.
-Reoperationwasrequiredin27patients(2.4%):procedurerelated:14patientsandvalverelated13patients.
-Morbiditycomprisedendocarditisin9patients;thromboembolismin8andanticoagulantrelatedcerebralhemorrhagein4pts.

CONCLUSIONS:-Transposition of chordae, marginalization of chordae and particularly

leaflet extension with autologous pericardium should be used for rheumatic mitral valve
insufficiency. Repeat mitral valve repair results in successful treatment for a minority of
rheumatic valve incompetence.

Conclusion : mitral valve repair is

clearly superior to MV replacement

lower operative risk

better preservation of ventricular function
lower risk of thromboembolic complications
less need for anticoagulation
improved hemodynamic performance
lower risk for endocarditis
better long-term survival
lower costs

TERIMA KASIH

Mitral valve repair in ischemic mitral regurgitation

Antonio Maria Calafiorea,*, Michele Di Maurob, Marco Continib, Luca
Welterta and Antonio Bivonab
Ischemic mitral regurgitation (IMR) is a common complication after acute
myocardial infarction due to annulus dilatation and papillary muscles displacement.
In our opinion 3/4 and 4/4 IMR have always to be indicated for MV surgery. In
presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected. The
end-systolic distance between the coaptation point of mitral leaflets and the plane of
mitral valve annulus is the key point to decide repair ( 10 mm) or replacement (>10
mm). MV annuloplasty has always been addressed to the posterior annulus, whose
size can be easily reduced. A specially designed 40 mm long ring has been used to
achieve a posterior overreductive annuloplasty. For MV repair thirty-day mortality
was 2.4%. Five-year survival and the possibility of being alive and in NYHA class III were 75.64.7 and 59.85.4, respectively. After a mean of 3835 months, the
NYHA class decreases from 3.20.5 to 2.10.6 (P<0.001). Most patients (77.4%)
have an improvement of its own functional class. MR decreases from 3.20.8 to
1.21.1 (P<0.001). 97.5% of the survivors have MR equal to or less than moderate.
Key Words: mitral valve ischemic mitral regurgitation mitral valve annulopasty

Acute mitral regurgitation is

more frequent and more
challenging for the surgeon
Antonio Maria
CALAFIORE
Professor of Cardiac Surgery
University of Catania
Chief, Division of Cardiac Surgery
Ferrarotto Hospital
Catania - Italy

Acute mitral regurgitation

Sudden alteration in mitral
structure due to:
@ papillary muscle rupture
@ papillary muscle
disfunction without rupture
(ischemia)

Clinical presentation
Sudden appearance of
symptoms and signs of severe
pulmonary venous
hypertension.

Natural history
In a series of 1480 consecutive patients who
had emergency catheterization within 6
hours after AMI, 50 (3.4%) had 3+ or 4+ MR.
In these patients mortality was 24% at 30
days, 42% at 6 months and 52% at 1 year.

Tcheng et al. Outcome of patients sustaining acute

ischemic
mitral regurgitation during myocardial infarction.
Ann Int Med 1992;117:18-24

Natural history
In a series of 1190 patients with cardiogenic
shock following AMI, the cohort with acute
MR (n=98) was compared to the cohort with
predominant LV failure (n=879).
Despite having higher EF (39% vs 30%), MR
patients had the same in hospital mortality
(55% vs 61%).

Thompson et al. Cardiogenic shock due to acute severe mitral

regurgitation complicating acute myocardial infarction: a report
from the SHOCK trial. JACC 2000;36:1004-9

Natural history
In the subgroup of patients with acute MR
(n=98), 43 underwent valve surgery and 51
did not.
In-hospital mortality was 40% in the
surgical group and 71% in the non surgical
group (p<0.001).

Thompson et al. Cardiogenic shock due to acute severe mitral

regurgitation complicating acute myocardial infarction: a report
from the SHOCK trial. JACC 2000;36:1004-9

March 2003 February 2006

Mitral valve surgery for acute mitral
regurgitation was performed
in 27 patients.

Antonio Maria
CALAFIORE

Surgical management
Initial hemodynamic stabilization
(IABP mandatory)
TT or TE echocardiography to assess the
mechanism of MR and LV function
Coronary angiography should be done
whenever possible

Surgical findings :

PM rupture 18 (66.7%)
PM dysfunction 9 (33.3%)

Surgical strategy

MV replacement 23 (85.2%)
+ CABG
18
(85.7%)
MV repair
4 (14.8%)
+ CABG
4
(100%)

Acute MR following AMI

n=27

Early deaths (30 days)

during surgery
after surgery

Late deaths

10 (37.0%)
3 (11.1%)
7 (25.9%)

3 (11.1%)

Acute MR following AMI n=27

No risk factors for early mortality
were identified, but a trend for
higher mortality in patients with
ejection fraction equal or lower
than 25%.

Antonio Maria
CALAFIORE

Surgical Result
55 consecutive patients with acute MR had valve
surgery (mean 7 days after AMI).
In-hospital mortality was 24%.
Absence of coronary revascularization was
associated with increased mortality (34% vs 9%,
p=0.02).
There was nothing to be gained in deferring
surgery.

Chevalier et al. Perioperative outcome and long term survival for

acute post-infarction mitral regurgitation.
Eur J Cardiothoracic Surg 2004;26:330-5

Surgical results

Chevalier et al. Perioperative outcome and long term survival for

acute post-infarction mitral regurgitation.
Eur J Cardiothoracic Surg 2004;26:330-5

Surgical management
Surgery should be performed without
delay: no benefit in waiting
Complete myocardial revascularization
improves the early outcome
Mitral valve has to be replaced in most
of the cases, but repair can be
attempted if the PM is not ruptured

Acute mechanical complications of

AMI are severe life-threatening
situations that need often urgent
surgical treatment without any delay.
Results are suboptimal (worse for
VSD, better for FW rupture), but are
related to the extent of the necrosis
and to the cardiogenic shock strictly
related to the complications.

Minimally
invasive mitral
valve repair.
Partial upper
sternotomy
provides access.
The mitral valve
is approached
via an extended
transseptal
incision.

Robotic Operation the

future

Mitral Valve Disease :

Treatment

Mitral Stenosis

Medical Rx for Class I & II

HR control Dig & BB

Anticoagulation

Afib, >40yrs, LAE, MR,

prior embolic event

Surgical Rx -Class III &IV

Balloon Mitral
Valvuloplasty
Commissural fusion
pliable, noncalcified
leaflets
No MR of LA thrombus
Mitral Valve Surgery
Open commissurotomy
MV replacement

Chronic Mitral
Regurgitation

Medical Rx for mild to mod

MR with vasodilators,
diuretics, anticoagulation
Surgical Rx ideally before
LV systolic function
declines.

MV replacement
MV ring & CABG
MR repair associated
with improved long-term
LV funvtion

MVP, ruptured chords,

infective endocadritis,
pap ms rupture.