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cardio.mitral-regurgitation.primary-chronic.v1PRODUCTION
cardio.mitral-regurgitation.primary-chronic.v1

Chronic primary (degenerative) mitral regurgitation

cardiologychronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm primary (leaflet) mechanism; if functional → cardio.mitral-regurgitation.secondary-chronic.v1; if acute severe → cardio.cardiogenic-shock.acute-mitral-regurgitation.v1

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primary chronic mechanism confirmed

Patient inputs (13)

Primary (leaflet) vs secondary (annular/ventricular) determines the entire pathway

EROA/RegVol/RF/vena contracta → ACC/AHA stage

Surgical-risk + repair-durability + TEER candidacy

LVEF 30–60% in severe primary MR = Class I surgery trigger

LV end-systolic diameter ≥40 mm in severe primary MR = Class I surgery trigger

Symptomatic severe (stage D) = Class I surgery if LVEF >30

Pre-procedure contrast risk + AC dosing

New AF = Class IIa intervention trigger + AC + concomitant maze

Bileaflet MVP + mitral annular disjunction → SCD risk workup

PASP >50 mmHg → Class IIa intervention in asymptomatic severe

LA enlargement supports chronicity + AF risk

Rising BNP supports earlier intervention in asymptomatic severe

STS/EuroSCORE → surgery vs TEER vs surveillance

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationalsevereclass_I_surgery_trigger_symptomatic
    Symptomatic severe primary MR with LVEF >30% — Class I mitral surgery (repair preferred) — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereclass_I_surgery_trigger_lv
    Asymptomatic severe primary MR with LVEF 30–60% OR LVESD ≥40 mm — Class I surgery — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverearrhythmic_mvp_special_pop
    Bileaflet MVP + mitral annular disjunction + complex ventricular ectopy/NSVT — SCD risk; Holter + CMR (LGE), consider ICD if malignant arrhythmia — arrhythmic-MVP literature
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_special_pop
    Severe primary MR + pregnancy/planning — pre-pregnancy repair preferred; if pregnant use diuretic + hydralazine (avoid ACEi/ARB); mWHO risk class; cardio-obstetric team — ESC 2018 Pregnancy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereendocarditis_related
    New/worsening MR with fever/vegetation — infective endocarditis driving leaflet destruction — route to IE engine for surgery timing — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaf_special_pop
    New AF in severe primary MR — Class IIa intervention trigger; anticoagulate by CHA₂DS₂-VASc; concomitant maze + LAA at surgery — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepulmonary_htn_special_pop
    PASP >50 mmHg in asymptomatic severe primary MR — Class IIa intervention — 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateelderly_high_risk_special_pop
    Elderly / prohibitive surgical risk + severe symptomatic primary MR — TEER vs medical; frailty + life-expectancy assessment — EVEREST II; 2020 ACC/AHA VHD
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateckd_special_pop
    CKD — pre-procedure contrast-nephropathy mitigation; renal-adjusted AC dosing (apixaban per criteria; avoid dabigatran if eGFR <30) — KDIGO 2024
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Primary MR severity/symptom/LV-staged management ladder — surveillance interval → asymptomatic-severe trigger thresholds → intervention; NO disease-modifying drug (2020 ACC/AHA VHD; 2021/2025 ESC/EACTS VHD)
axis: primary_mr_severity_symptom_lv_stagedstep 1 - Stage B — mild/moderate primary MR: surveillance interval BY SEVERITY, no AS-of-MR-directed pharmacotherapy
Selected step "Stage B — mild/moderate primary MR: surveillance interval BY SEVERITY, no AS-of-MR-directed pharmacotherapy" — Mild (EROA <0.20 cm² / RegVol <30 mL / RF <30%) or moderate (EROA 0.20–0.39 / RegVol 30–59 / RF 30–49%) primary MR, asymptomatic, preserved LV
  • clinical surveillance (no primary-MR-directed pharmacotherapy)
    first line
    watchful_waiting
    triggers: mild_primary_MR, moderate_primary_MR, asymptomatic
    No drug alters primary-MR natural history. Watchful-waiting yields survival ≈ expected: Rosenhek Circulation 2006 (PMID 16651470); Zilberszac JACC-Img 2018 overall-survival SMR 0.667 (0.463–0.963), P=0.013 (PMID 30031699). Surveillance TTE q1–2 y (moderate) per 2020 ACC/AHA VHD (PMID 33342586)

outpatient playbook — drug actions (2)

  1. 1. loop diuretic
    furosemide 20–40 mg • PO • daily
    trigger: Congestion bridge (2020 ACC/AHA VHD)
    Symptom control only — no natural-history effect
  2. 2. rate control + anticoagulation if AF
    metoprolol + apixaban • PO • BID
    trigger: AF + primary MR (2020 ACC/AHA VHD)
    Stroke prevention + rate control; warfarin if rheumatic

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Apical holosystolic murmur radiating to axilla; Echo: severe primary MR (EROA ≥0.40 cm², RegVol ≥60 mL, RF ≥50%); Echo: MV prolapse / flail leaflet.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Chronic primary (degenerative) mitral regurgitation** (cardio.mitral-regurgitation.primary-chronic.v1).
Phenotype framing: Primary vs secondary MR vs MVP without significant MR vs mixed valve disease
Scope: Confirm primary (leaflet) mechanism; if functional → cardio.mitral-regurgitation.secondary-chronic.v1; if acute severe → cardio.cardiogenic-shock.acute-mitral-regurgitation.v1

No severity triggers fired against current inputs.

Plan

Regimen axis: **Primary MR severity/symptom/LV-staged management ladder — surveillance interval → asymptomatic-severe trigger thresholds → intervention; NO disease-modifying drug (2020 ACC/AHA VHD; 2021/2025 ESC/EACTS VHD)** — step "Stage B — mild/moderate primary MR: surveillance interval BY SEVERITY, no AS-of-MR-directed pharmacotherapy".
1. clinical surveillance (no primary-MR-directed pharmacotherapy) (watchful_waiting, first line) — No drug alters primary-MR natural history. Watchful-waiting yields survival ≈ expected: Rosenhek Circulation 2006 (PMID 16651470); Zilberszac JACC-Img 2018 overall-survival SMR 0.667 (0.463–0.963), P=0.013 (PMID 30031699). Surveillance TTE q1–2 y (moderate) per 2020 ACC/AHA VHD (PMID 33342586)

Setting playbook (outpatient) — Stage primary MR, refer for repair at the correct trigger before irreversible LV remodeling, surveil the rest (2020 ACC/AHA VHD)
2. loop diuretic furosemide 20–40 mg PO daily — Congestion bridge (2020 ACC/AHA VHD) (Symptom control only — no natural-history effect)
3. rate control + anticoagulation if AF metoprolol + apixaban PO BID — AF + primary MR (2020 ACC/AHA VHD) (Stroke prevention + rate control; warfarin if rheumatic)

Non-pharmacologic actions:
- Refer to primary mitral-valve reference center for repair when Class I/IIa trigger met — 2020 ACC/AHA VHD
- Endocarditis prophylaxis only if prior IE or prosthetic material — 2020 ACC/AHA VHD
- Arrhythmic-MVP SCD workup (Holter, CMR) if bileaflet MVP + mitral annular disjunction — arrhythmic-MVP literature

AVOID / contraindication checks:
- No disease modifying drug for primary MR — no RCT shows a pharmacologic agent alters asymptomatic normotensive primary MR natural history (2020 ACC/AHA VHD, PMID 33342586)
- Vasodilators ACEi ARB not indicated asymptomatic normotensive primary MR — do NOT delay surgery (2020 ACC/AHA VHD)
- Avoid delay surgery once class I trigger met LV irreversible — Ling NEJM 1996 (PMID 8875918); Avierinos ageing (PMID 23853072)
- TEER only if favorable anatomy and prohibitive surgical risk PRIMARY MR — EVEREST II (PMID 26718672); 2020 ACC/AHA VHD
- Repair preferred over replacement degenerative MR — Lazam MIDA (PMID 27899396)

Monitoring

Regimen monitoring:
- TTE q6-12mo severe asymptomatic — 2020 ACC/AHA VHD (PMID 33342586)
- TTE q1-2yr moderate — 2020 ACC/AHA VHD
- serial EROA RegVol LVEF LVESD PASP LA for intervention trigger — Enriquez-Sarano NEJM 2005 (PMID 15745978); Rusinaru LA (PMID 21737598)
- AF surveillance pulse or device — Grigioni MIDA AF (PMID 30678755)
- post-repair TTE at baseline then annually — 2020 ACC/AHA VHD

Setting (outpatient) monitoring:
- Serial TTE per severity (severe asymptomatic q6–12 mo) — 2020 ACC/AHA VHD
- Symptom + AF surveillance each visit — 2020 ACC/AHA VHD

Follow-up plan: Post-repair surveillance; route to HFrEF engine if LV dysfunction (stage C2) develops
- Close-out criterion: follow-up + escalation triggers documented

Monitoring phase: Serial TTE by severity (severe asymptomatic q6–12 mo; moderate q1–2 yr); symptom + AF surveillance

Disposition

Current setting: outpatient — Stage primary MR, refer for repair at the correct trigger before irreversible LV remodeling, surveil the rest (2020 ACC/AHA VHD)

Disposition criteria:
- Asymptomatic non-severe → routine surveillance
- Class I/IIa trigger → mitral surgery referral (repair center)
- Prohibitive surgical risk + severe symptoms → TEER evaluation

Escalation triggers (move to higher acuity):
- Symptoms OR LVEF ≤60% OR LVESD ≥40 mm OR new AF OR PASP >50 → surgical referral now — 2020 ACC/AHA VHD
- Flail with decompensation → ED + acute MR pathway — 2020 ACC/AHA VHD
- Syncope / malignant arrhythmia in arrhythmic MVP → EP + ICD evaluation — arrhythmic-MVP literature

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Symptomatic severe primary MR with LVEF >30% — Class I mitral surgery (repair preferred) — 2020 ACC/AHA VHD
- [SEVERE] Asymptomatic severe primary MR with LVEF 30–60% OR LVESD ≥40 mm — Class I surgery — 2020 ACC/AHA VHD
- [SEVERE] Bileaflet MVP + mitral annular disjunction + complex ventricular ectopy/NSVT — SCD risk; Holter + CMR (LGE), consider ICD if malignant arrhythmia — arrhythmic-MVP literature

Citations

- 2020 ACC/AHA VHD Guideline (Otto/Nishimura, JACC 33342586 / Circ 33332149) + 2021 ESC/EACTS VHD Guideline (Vahanian 34453165); 2025 ESC/EACTS VHD LVESDi refinement layered on [PMID:33342586](https://pubmed.ncbi.nlm.nih.gov/33342586/)
- Cited evidence (PMID 33332149) [PMID:33332149](https://pubmed.ncbi.nlm.nih.gov/33332149/)
- Cited evidence (PMID 34453165) [PMID:34453165](https://pubmed.ncbi.nlm.nih.gov/34453165/)
- Cited evidence (PMID 15745978) [PMID:15745978](https://pubmed.ncbi.nlm.nih.gov/15745978/)
- Cited evidence (PMID 8875918) [PMID:8875918](https://pubmed.ncbi.nlm.nih.gov/8875918/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2020 ACC/AHA VHD Guideline (Otto/Nishimura, JACC 33342586 / Circ 33332149) + 2021 ESC/EACTS VHD Guideline (Vahanian 34453165); 2025 ESC/EACTS VHD LVESDi refinement layered on — PMID:33342586
  • Cited evidence (PMID 33332149) — PMID:33332149
  • Cited evidence (PMID 34453165) — PMID:34453165
  • Cited evidence (PMID 15745978) — PMID:15745978
  • Cited evidence (PMID 8875918) — PMID:8875918