Mitral valve repair is the most appropriate option for this patient with asymptomatic severe mitral regurgitation and moderate left ventricular (LV) dysfunction. Surgery is indicated for patients with symptomatic acute severe mitral regurgitation, those with symptomatic chronic severe mitral regurgitation with LV ejection fraction greater than 30%, and asymptomatic patients with chronic severe mitral regurgitation and mild to moderate LV dysfunction (ejection fraction of 30%-60% and/or LV end-systolic dimension ≥40 mm). Mitral valve repair is the operation of choice when the valve is suitable for repair and appropriate surgical skill is available and is recommended for most patients. Mitral valve replacement, especially with chordal preservation, is appropriate for patients with severe mitral regurgitation in whom the valve is not repairable or a less than optimal result would be obtained. Recently, a percutaneously placed mitral valve clip has been introduced that is placed to better approximate the edges of the anterior and posterior leaflets of the valve and may be a therapeutic option in patients who are at a prohibitive risk for mitral valve surgery.

Vasodilator therapy, such as with ACE inhibitors or angiotensin receptor blockers, has not been shown to improve outcomes in patients with severe mitral regurgitation who are asymptomatic. Additionally, vasodilator therapy may mask the development of more severe left ventricular dysfunction due to regurgitant volume. Therefore, these agents should not be used as a substitute therapy for surgery when the patient is thought to be a surgical candidate.

Mitral balloon valvuloplasty or valvotomy is indicated for patients with severe mitral stenosis in whom there is a reasonable likelihood of success and in whom there are no contraindications (such as moderate to severe mitral regurgitation or left atrial thrombus). This patient has severe mitral regurgitation, and repair, not valvotomy, is indicated.

Serial echocardiography may be helpful in follow-up of the asymptomatic patient in whom worsening of LV systolic function or increase in chamber size may help facilitate decision for surgery. This patient's LV function is compromised and intervention is indicated.