This protocol applies to asymptomatic patients with mitral valve prolapse who have progressed to severe primary mitral regurgitation at Stage C2 and show evidence of left ventricular systolic dysfunction — a pattern that demands active management even in the absence of symptoms.
Severe primary mitral regurgitation classified as Stage C2, in an asymptomatic patient, with left ventricular systolic dysfunction present — defined as a left ventricular ejection fraction of 60% or less, or a left ventricular end-systolic dimension of 40 mm or greater. The reduced ejection fraction in this setting represents a critical threshold that changes the management calculus.
When surgery cannot be performed immediately or must be deferred, guideline-directed medical therapy targeting LV systolic dysfunction becomes the core intervention — with beta-adrenergic blockade forming one component of a broader regimen. The complete agent selection, sequencing, and clinical decision tree are available in the full structured protocol.
In asymptomatic patients with severe primary MR and LV systolic dysfunction (LVEF ≤60%, LVESD ≥40 mm) (Stage C2), mitral valve surgery is recommended.
In symptomatic or asymptomatic patients with severe primary MR and LV systolic dysfunction (Stages C2 and D) in whom surgery is not possible or must be delayed, GDMT for systolic dysfunction is reasonable.
Although data specific to patients with MR with LV dysfunction are sparse, treatment of such patients would consist of the standard regimen for HF, including beta-adrenergic blockade, ACE inhibitors or ARBs, and possibly aldosterone antagonists.
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