A 52-year-old man from Delhi presents with progressive dyspnea on exertion (NYHA Class III) and orthopnea for 6 months. On examination, he has an apical pan-systolic murmur radiating to the axilla, elevated JVP, hepatomegaly, and peripheral edema. Echocardiography confirms severe mitral regurgitation (MR) with an ejection fraction of 35%. He is currently on lisinopril 10 mg daily and bisoprolol 5 mg daily. What is the most appropriate next step in management?

Clinical Assessment

This patient has symptomatic severe mitral regurgitation with reduced ejection fraction (EF 35%) and NYHA Class III symptoms despite optimal medical therapy with an ACE inhibitor and beta-blocker.

Key Point:

Symptomatic severe MR with EF ≤40% is a Class I indication for surgical intervention (valve repair or replacement), regardless of whether the patient is on maximal medical therapy. Medical management alone cannot prevent progressive ventricular dysfunction in severe organic MR.

High-Yield:

Indications for surgery in mitral regurgitation:

Clinical Pearl:

In primary (organic) MR due to structural valve disease, the regurgitant volume itself causes progressive LV dilatation and dysfunction. Surgery should not be delayed until EF falls further, as this worsens surgical outcomes and prognosis.

Mnemonic:

SEVERE MR + REDUCED EF = SURGERY

Rationale for Correct Answer:

Referral for mitral valve repair/replacement is the standard of care because:

Harrison 21e Ch 282

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