Q. Medical Management of mitral regurgitation?

Vasodilator therapy to reduce afterload may be beneficial in patients with chronic mitral regurgitation, but there is no evidence to suggest the same in an asymptomatic patient. In a symptomatic patient with primary mitral regurgitation, surgery should be done. Vasodilators should be used in a symptomatic patient with primary or secondary mitral regurgitation not undergoing surgery. Beta blockers, digoxine, calcium channel blockers and even amiodarone may have to be used for rate control in a patient with atrial fibrillation. Diuretics need to be given as required. Oral anticoagulants are indicated in a patient with atrial fibrillation to prevent embolic episodes though the rate of embolic episodes is low and INR in the range of 2.0-2.5 may be sufficient.

Serial Follow Up

Serial follow up will help to identify patients who develop symptoms and left ventricular dysfunction. It is important to identify early signs of left ventricular dysfunction since left ventricular dysfunction may precede symptoms and post-operative outcome depends upon the left ventricular size and function. Patients with mild mitral regurgitation with no left ventricular dilatation need to be followed once in a year. Annual echocardiograms are not indicated unless they develop new symptoms. Patients with moderate mitral regurgitation need annual evaluation including echocardiography. Patients with severe mitral regurgitation should be followed up once in six months to assess symptoms and left ventricular size and function. Even in an asymptomatic patient left ventricular end systolic dimension more than 45 mm and left ventricular ejection fraction less than 60 per cent are indications for mitral valve repair or replacement. When history is not obvious, exercise testing may be done to assess functional capacity objectively.