The most appropriate treatment for this patient is mitral valve replacement (MVR) with a bioprosthetic valve. She has a history of rheumatic fever and extensive degeneration of the mitral valve with severe mitral regurgitation on echocardiogram, consistent with rheumatic heart disease. Indications for mitral valve surgery include symptomatic severe mitral regurgitation with left ventricular (LV) ejection fraction greater than 30% and asymptomatic severe mitral regurgitation with mild to moderate LV dysfunction (ejection fraction of 30%-60% and/or LV end-systolic diameter ≥40 mm). Although surgical valve repair is generally preferred to valve replacement, it may not be possible with extensive calcification of the valve leaflet or annulus, prolapse of more than one third of the leaflet tissue, or extensive destruction of the chordal apparatus. The choice of valve intervention and prosthetic valve type should be a shared decision-making process. When valve replacement is indicated, as in this patient, a bioprosthesis is preferred in patients of any age for whom anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired. In addition, a bioprosthesis is a reasonable choice for patients older than 70 years. This patient's history of gastrointestinal bleeding and her advanced age make a bioprosthetic valve the more reasonable choice.

Intravenous vasodilator therapy improves forward blood flow and symptoms acutely in patients with severe mitral regurgitation. However, there is little evidence that long-term oral vasodilator therapy is beneficial for symptomatic mitral regurgitation, and it is used primarily in patients unable to undergo surgical correction. Because this patient has no clear contraindication to surgical therapy, medical therapy alone would not be appropriate.

Percutaneous mitral valve repair procedures include percutaneous valvuloplasty or implantation of a clip to reduce regurgitant flow. However, these procedures are either under investigation or their use is limited to a small group of patients.