A 54-year-old man with severe chronic primary mitral regurgitation due to posterior leaflet prolapse has LVEF of 63%, LV end systolic diameter of 42 mm, and no symptoms on exercise testing. According to guideline triggers for mitral valve repair, which finding mandates referral for surgery?

• A Left atrial diameter of 35 mm
• B End systolic diameter of 38 mm
• C Asymptomatic status with normal exercise capacity
• D LVEF below 60% ✓

Explanation

For severe chronic primary mitral regurgitation, surgery is indicated once LVEF falls below 60% or LV end systolic diameter reaches 40 mm or more, since these mark irreversible left ventricular dysfunction; waiting until conventional heart failure thresholds would be too late. An end systolic diameter of 38 mm lies below the trigger, and mild atrial dilatation or preserved functional capacity alone does not mandate operation.

Reference: Braunwald's Heart Disease, 12th ed.

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