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MR LVESD Threshold 2025 — EECC MCQ

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ModerateValvular Heart DiseaseMR LVESD Threshold 2025EECC

A 60-year-old man with chronic severe MR due to posterior mitral leaflet prolapse (P2 flail) has LVEF 58%, LVESD 42 mm, and sinus rhythm. He is NYHA class I. The ESC 2025 VHD Guidelines recommend earlier intervention in asymptomatic severe primary MR. What is the new recommended surgical threshold for LVESD?

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Correct answer: E — LVESD ≥40 mm (previously ≥45 mm in earlier guidelines) is now a trigger for surgery in asymptomatic severe primary MR when repair is likely at an expert centre

The 2025 ESC/EACTS VHD Guidelines lowered the LVESD threshold for surgical intervention in asymptomatic severe primary MR from ≥45 mm to ≥40 mm (Class IIa when repair is feasible at an expert centre with low operative mortality). This reflects evidence that LV dysfunction in MR occurs at smaller LV dimensions than previously appreciated, and that earlier surgery (before irreversible LV remodelling) produces better long-term outcomes. Additional Class I/IIa triggers for surgery in asymptomatic primary MR include: LVEF ≤60%, new AF, PASP >50 mmHg at rest, LA dilatation (LAVi >40 mL/m²), and flail leaflet with EROA ≥40 mm² when repair is highly likely at a reference centre.

Reference: ESC/EACTS (2025): VHD Guidelines