A 40-year-old man with severe primary degenerative mitral regurgitation, LVEF 62%, no symptoms on treadmill testing, and no pulmonary hypertension undergoes annual follow-up. At what point do current guidelines recommend mitral valve repair even in the absence of symptoms?

• A When the patient reaches 65 years of age regardless of other parameters
• B Only when LVEF falls below 50% or NYHA class III symptoms develop
• C When the regurgitant jet occupies any part of the left atrium on colour Doppler
• D When resting LVEF falls to 60% or less, or LV end-systolic diameter reaches 40 mm or more ✓

Explanation

For chronic primary severe MR, surgery is indicated once LV dysfunction is detected, defined as LVEF of 60% or less or LV end-systolic diameter of 40 mm or more, even in asymptomatic patients, because these thresholds predict post-operative LV dysfunction. Waiting for EF below 50% means irreversible myocardial damage has already occurred. Jet area on colour Doppler grades severity but does not by itself trigger surgery, and age alone is never an indication.

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

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Written and medically reviewed by the StethoPrep medical team.