A 62-year-old man presents with progressive exertional dyspnea and palpitations over 4 months. On examination, he has a holosystolic murmur at the apex radiating to the axilla and a loud S3. Transthoracic echocardiography reveals degenerative myxomatous mitral disease. The structure marked **A** in the diagram shows flail of the P2 scallop with free edge prolapsing into the left atrium due to ruptured chordae tendineae. The regurgitant volume is 65 mL with an EROA of 0.45 cm². LV end-diastolic diameter is 62 mm and LVEF is 60%. Given this presentation and imaging findings, which of the following is the most appropriate management?
A. Conservative management with diuretics and ACE inhibitors alone
B. Mitral valve repair with triangular resection, neochord implantation, and annuloplasty ring placement
C. Mitral valve replacement with a mechanical prosthesis
D. Transcatheter edge-to-edge repair (MitraClip) as first-line therapy
Explanation
Why Mitral valve repair with triangular resection, neochord implantation, and annuloplasty ring placement is right
The patient has symptomatic severe primary mitral regurgitation due to flail of the posterior leaflet (P2 scallop) — a hallmark of degenerative myxomatous mitral disease. According to the ACC/AHA Valvular Heart Disease Guideline 2020 and Carpentier Reconstructive Surgery principles, symptomatic severe MR is a Class I indication for surgery. Mitral valve repair is strongly preferred over replacement when feasible because it preserves the subvalvular apparatus, avoids prosthesis-related complications, and confers superior long-term survival. An isolated P2 flail is achievable in >95% of cases at high-volume centers using techniques including triangular or quadrangular resection, neochord implantation (Gore-Tex), and annuloplasty ring placement. This patient is an ideal candidate for repair given the focal nature of the lesion and preserved LVEF.
Why each distractor is wrong
Mitral valve replacement with a mechanical prosthesis: While technically feasible, replacement is reserved for cases where repair is not possible or has failed. Replacement carries higher morbidity (anticoagulation, prosthesis-related complications, reduced long-term survival) and should not be first-line in a patient suitable for repair.
Conservative management with diuretics and ACE inhibitors alone: The patient is symptomatic with severe MR (regurgitant volume 65 mL, EROA 0.45 cm²), exertional dyspnea, atrial fibrillation, and mild pulmonary hypertension. Medical therapy alone is inadequate and delays necessary surgical intervention, risking progressive LV dilatation and dysfunction.
Transcatheter edge-to-edge repair (MitraClip) as first-line therapy: TEER is reserved for patients who are unsuitable for surgery due to prohibitive surgical risk, comorbidities, or advanced age. This patient is a good surgical candidate with focal P2 flail, making surgical repair the preferred approach with superior long-term outcomes.
High-YieldNEET PG
Symptomatic severe primary MR due to flail posterior leaflet → mitral valve repair is strongly preferred over replacement at high-volume centers; isolated P2 flail is repairable in >95% of cases.
ACC/AHA Valvular Heart Disease Guideline 2020; Carpentier Reconstructive Surgery
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