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status and coronary anatomy, expected completeness severe, secondary mitral regurgitation who are judged
of revascularization, coexisting valvular disease and inoperable or at high surgical risk, percutaneous
co-morbidities. mitral valve intervention (percutaneous edge-to-
edge repair) may be considered in order to improve
Primary (organic) mitral regurgitation symptoms and quality of life, although no RCT
Surgery is indicated in symptomatic patients with evidence of improvement has been published, only

severe organic mitral regurgitation with no contra- registry studies.
indications to surgery. The decision of whether to
replace or repair depends mostly on valve anatomy, Aortic stenosis
surgical expertise available, and the patient’s In symptomatic patients with reduced LVEF and
condition. When the LVEF is < 30%, a durable surgical low flow low gradient AS( valve area< 1cm2,LVEF
repair may improve symptoms, although its effect on <40% mean pressure gradient <40 mmHg), low-
survival is unknown. In this situation, the decision to dose dobutamine stress echocardiography should
operate should take account of response to medical be considered to identify those with severe aortic
therapy, co-morbidities, and the likelihood that the stenosis suitable for valve replacement. IIa C TAVI is
valve can be repaired (rather than replaced). recommended in patients with severe aortic stenosis
who are not suitable for surgery as assessed by a
Secondary mitral regurgitation ‘heart team’ and have predicted post-TAVI survival
This occurs because LV enlargement and remodelling >1 year. I B
lead to reduced leaflet closing. Effective medical TAVI should be considered in high-risk patients with
therapy (including CRT in suitable patients) leading to severe aortic stenosis who may still be suitable for
reverse remodelling of the LV may reduce functional surgery, but in whom TAVI is IIa
mitral regurgitation, and every effort should be made
to optimize medical treatment in these patients. In patients with severe aortic regurgitation, aortic
Combined valve and coronary surgery should be valve repair or replacement is recommended in all
considered in symptomatic patients with LV systolic symptomatic patients and in asymptomatic patients
dysfunction (LVEF < 30%), coronary arteries suitable with resting LVEF who are otherwise fit for surgery.
for revascularization, and evidence of viability.
Conclusions;
Surgery is also recommended in patients with severe
mitral regurgitation undergoing CABG with LVEF < Heart failure is the emerging epidemic of the
30%. twenty first century with a projected 25% increase
in prevalence by 2030.In spite of multiple advances
However, a recent study in patients with moderate, in therapy , the mortality and re- hospitalizations
secondary ischaemic mitral regurgitation did not prove remain unacceptably high.However this serious
that the addition of mitral valve repair to CABG would threat is underrecognized by the public and health
lead to a higher degree of LV reverse remodelling. care professionals.A team approach is mandatory to
Also, there is no evidence favouring mitral valve repair tackle this serious malady.
over replacement in the context of better outcomes Suggested reading
and magnitude of LV remodelling.In the presence of
AF, atrial ablation and LA appendage closure may 1. McMurray . Eur Heart J 2001 Jun 3 (3) 315-22.
be considered at the time of mitral valve surgery. The 2. Journal of practice of cardiovascular sciences 2015 : Volume 1; Issue
role of isolated mitral valve surgery in patients with : 1 : Page : 35-38 Epidemiology of acute decompensated heart failure
severe functional mitral regurgitation and severe LV in India : The AFAR study (Acute failure registry study) Sandeep Seth,
Suraj Khanal, Sivasubramanian Ramakrishnan, Namit Gupta, Vinay K Bahl
systolic dysfunction (LVEF < 30%) who cannot be
revascularized or have non-ischaemic 3. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. European Heart Journal (2016) 37, 2129–2200.
cardiomyopathy is questionable, and in most 4. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline
patients conventional medical and device therapy are for the Management of Heart Failure. Journal of the American College
preferred. In selected cases, repair may be considered of Cardiology April 2017
in order to avoid or postpone transplantation.
The decision should be based on comprehensive
evaluation (including strain echocardiography or
magnetic resonance imaging and discussed within
the ‘heart team’. In patients with HF with moderate-

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