Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

asymptomatic

1st line – reassurance

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ACUTE
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asymptomatic
1st line – 

reassurance

Most asymptomatic patients with MVP need no specific treatment and should be reassured of their excellent prognosis. Normal lifestyle and regular exercise should be encouraged. Patients who have a dilated left ventricle, left atrial dilation, pulmonary hypertension, and new atrial fibrillation can be considered for surgery in combination with other clinical factors.

Mitral regurgitation (MR) is common in MVP. Most patients are asymptomatic. No specific therapy is required for mild MR.

Consider – anticoagulation or antiplatelet therapy

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ACUTE
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asymptomatic
Consider – 

anticoagulation or antiplatelet therapy

Additional treatment recommended for SOME patients in selected patient group

Depending on the presence of further risk factors, aspirin, warfarin, or a direct oral anticoagulant is recommended in people with concurrent atrial fibrillation, or a history of stroke or TIA.[1][46][47]

Consider – mitral valve repair

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ACUTE
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asymptomatic
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with severe primary mitral regurgitation
Consider – 

mitral valve repair

Additional treatment recommended for SOME patients in selected patient group

Severe primary MR may warrant early consideration for surgical intervention. For asymptomatic patients, surgery is indicated for left ventricular (LV) dysfunction (ejection fraction ≤60%, LV end-systolic diameter ≥40 mm).[1][47]​​ Intervention for severe primary MR is also considered for those with elevated pulmonary artery pressure, atrial fibrillation, or when there is significant left atrial dilatation and when there is a high likelihood of successful surgical repair and a low surgical risk.[1][47][49]

There is some controversy over the management of patients without evidence of LV dysfunction, pulmonary hypertension, or atrial fibrillation. American College of Cardiology/American Heart Association guidelines have recommended mitral valve surgery as reasonable for this group, in experienced surgical centres, in cases where the likelihood of repair is >95% and operative mortality is ≤1%, or if there is a progressive increase in LV size or progressive decrease in EF on ≥3 serial imaging studies.[49] The European Society of Cardiology recommends watchful waiting in asymptomatic patients with severe primary mitral regurgitation and no indications for surgery.[47]

Depending on the presence of further risk factors, aspirin, warfarin, or a direct oral anticoagulant is recommended in people with concurrent atrial fibrillation, or a history of stroke or TIA.[1][46]

symptomatic

1st line – urgent evaluation + confirmation of diagnosis

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ACUTE
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symptomatic
1st line – 

urgent evaluation + confirmation of diagnosis

Symptoms include palpitations, syncope, atypical chest pain, and anxiety. Evaluation of palpitations or syncope should mirror the work-up in patients without MVP, including evaluation with Holter or ambulatory event monitoring to rule out significant arrhythmias.

Plus – lifestyle modifications ± beta blockers

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ACUTE
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symptomatic
Plus – 

lifestyle modifications ± beta blockers

Treatment recommended for ALL patients in selected patient group

If Holter or event monitoring has been unrevealing, a trial of lifestyle changes, including avoidance of stimulants, may be effective, especially in those with increased adrenergic responses to stress and activity. Avoidance of caffeine, nicotine, and other stimulants may be beneficial. Reducing or eliminating alcohol may also be helpful. Regular exercise programme participation is generally advisable.

Restriction in competitive sport is recommended in the presence of moderate left ventricular enlargement or dysfunction, uncontrolled tachyarrhythmias, long QT interval, unexplained syncope, prior resuscitation from cardiac arrest, or aortic root enlargement.[50][51]

Empirical beta-blocker treatment may be useful in alleviating symptoms of palpitations, anxiety, or atypical chest pain in certain patients.[43]

Consider – anticoagulation or antiplatelet therapy

Back
ACUTE
|
symptomatic
Consider – 

anticoagulation or antiplatelet therapy

Additional treatment recommended for SOME patients in selected patient group

Depending on the presence of further risk factors, aspirin, warfarin, or a direct oral anticoagulant is recommended in people with concurrent atrial fibrillation, or a history of stroke or TIA.[1][46][47]

Plus – mitral valve repair or supportive medical therapy

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ACUTE
|
symptomatic
|
with severe regurgitation
Plus – 

mitral valve repair or supportive medical therapy

Treatment recommended for ALL patients in selected patient group

Both the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) guidelines stress the importance of performing mitral valve repair if feasible and referring patients to centres with appropriate surgical expertise.[1][47]

ACC/AHA and ESC guidelines recommend surgery for all symptomatic patients with severe chronic primary MR and acceptable surgical risk.[1][2][47] For symptomatic patients who are inoperable or at high surgical risk, transcatheter mitral valve intervention (transcatheter edge-to-edge repair) may be considered if mitral valve anatomy is favourable.[1][2][47]

Mitral valve repair is technically possible in most instances in prolapse or flail of the posterior leaflet but is more difficult in anterior leaflet prolapse, flail anterior leaflet, or bileaflet prolapse. The advantages of repair over replacement include lower operative and long-term mortality, better preservation of left ventricular systolic function, and avoidance of the need for anticoagulation associated with a mechanical prosthetic valve. Patients undergoing mitral valve repair are usually treated in the postoperative period with aspirin and require anticoagulation only if atrial fibrillation is present.[1]​​[2][47]​​​​

When surgery is indicated but is not possible or must be delayed, ACC/AHA guidelines recommend that guideline-directed medical therapy for systolic dysfunction may be considered.[1] ESC guidelines recommend medical treatment in line with current heart failure guidelines for patients with overt heart failure.[47]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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