Optimal timing of surgery is fundamental in the management of patients with mitral regurgitation. The only treatment in patients with mitral regurgitation is mitral valve surgery since no medical therapy is available. The current guidelines have been largely defined based on preoperative determinants of long-term postoperative outcome. The main indications for surgery include the onset of symptoms, left ventricular dysfunction (LVEF < 60%) and left ventricular enlargement (LVESD ≥ 45mm). If patients who are asymptomatic with preserved left ventricular function should be operated is still controversial.(1-2) Surgery should be considered in asymptomatic patients and preserved left ventricular function with new onset AF or pulmonary hypertension (systolic pulmonary arterial pressure > 50 mmHg at rest).
Studies are now focussing on these asymptomatic patients with preserved left ventricular function to identify these patients who are at higher risk and who might benefit from early surgery.Several risk factors for an unfavourable outcome have been identified:
Furthermore when considering surgery in a patient with a severe mitral regurgitation the probability of a durable valve repair is of crucial importance. A major contributing factor to successful repair is the hospital volume. Patients with predictable complex repair should undergo surgery in experienced repair centers with high repair rates and low operative mortality. When repair is not feasible, mitral valve replacement with preservation of the subvalvular apparatus is preferred.
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