Mitral Regurgitation · Repair vs Replacement

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Primary/secondary + surgical indication + risk
   Primary or secondary? Meets an indication? Surgical risk?
   • Primary (degenerative) severe, symptomatic or LVEF ≤60%/LVESD ≥40 mm/new AF/pulmonary hypertension → Primary meeting indication → surgery (repair preferred)
   • Primary severe, symptomatic but high/prohibitive surgical risk, suitable anatomy → High-risk primary → TEER
   • Secondary (functional), still symptomatic after GDMT, meets COAPT → Secondary → TEER (COAPT)
   • Asymptomatic mild-moderate or no indication met → No indication → follow up
2. [End] No indication → follow up
   No indication met → follow up (echo, symptoms) + treat the cause; primary severe but asymptomatic with normal LV function — monitor closely (operate once LV changes/AF/pulmonary hypertension appear).
3. [End] Primary meeting indication → surgery (repair preferred)
   Primary severe meeting indication → mitral surgery, repair over replacement (especially degenerative — durable, preserves subvalvular apparatus and function); high repair success at experienced centers; if not repairable, replace preserving the subvalvular apparatus.
4. [End] High-risk primary → TEER
   Primary severe, symptomatic, high/prohibitive surgical risk, suitable anatomy → transcatheter edge-to-edge repair (TEER/MitraClip).
5. [End] Secondary → TEER (COAPT)
   Secondary MR, still symptomatic after optimized guideline-directed medical therapy (GDMT), meeting COAPT anatomy → TEER; surgery in selected patients (often addressed during concurrent CABG/other cardiac surgery).

Source guidelines & references

• Mitral regurgitation management (2020 ACC/AHA; COAPT; repair over replacement)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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