Transesophageal echocardiography (TEE) would be the most appropriate next step in management of this patient. Evaluating the degree of mitral regurgitation and assessing the causative valve abnormalities provides essential information for guiding therapy, particularly whether surgical repair is possible or indicated. Although this information is usually obtained with transthoracic echocardiography, in situations in which full evaluation of the valve and degree of mitral regurgitation is not possible, such as in this very obese patient in whom accurate Doppler parameters cannot be obtained, TEE is indicated. Because the transducer in TEE is able to be closely approximated to the left atrium and mitral valve, structural details, including integrity of the valve leaflets and chordae, and the regurgitant jet, are almost always well visualized, allowing assessment of valvular abnormalities and accurate measurement of Doppler parameters. Chest CT angiography and cardiac magnetic resonance imaging may also be useful adjuvants, allowing assessment of coronary anatomy, valve structure, and coexisting structural heart disease. Three-dimensional echocardiography, both transthoracic and transesophageal, can further help identify leaflet and scallop involvement, likelihood of operative repair, and additional quantification of mitral regurgitation severity.

The decision to proceed with mitral valve surgery, including mitral valve repair, would be premature in this patient without adequate knowledge of the severity of mitral regurgitation and better definition of the underlying valvular abnormalities.

Although clinical follow-up with serial echocardiography may be appropriate for this patient, the appropriateness of this management strategy depends upon adequate initial evaluation of her mitral valve disease.

Medical therapy for patients with asymptomatic mitral regurgitation is limited. To date, no studies have shown benefit of ACE inhibitors, angiotensin receptor blockers, or diuretics in the absence of another specific indication, such as hypertension, left ventricular systolic dysfunction, or evidence of volume overload. This patient has none of those features.