A 50-year-old female presents with a history of idiopathic dilated cardiomyopathy. Over the past 6 months, she has become increasingly short of breath and has been requiring higher doses of diuretics. An echocardiogram reveals an ejection fraction of 20%, which is unchanged; however, severe central mitral regurgitation is present. She is optimized on ACE inhibitors, beta-blockers, spironolactone and digoxin. An ECG shows a left bundle branch block and sinus rhythm. Which of the following is the next appropriate course of action?
A. Mitral valve repair or replacement
B. Biventricular pacing
C. Add nifedipine for further afterload reduction
D. The Alfieri stitch
Mitral valve repair or replacement from functional mitral regurgitation (this case) only receives a class IIb indication when the ejection fraction is less than 30% and there is persistent functional class III or IV heart failure despite optimal medical therapy and biventricular pacing.
The Alfieri stitch is a surgical technique used to treat severe mitral regurgitation; a suture was placed between the A2 and P2 segments of the mitral valve, resulting in two mitral valve orifices. It has been shown to significantly reduce the degree of mitral regurgitation but may result in some degree of mitral stenosis. This is best suited for functional mitral regurgitation from annular dilation. Inserting a clip percutaneously between the A2 and P2 mitral valve leaflet segments has been done successfully, although research to support its use is lacking. This is not a standard therapy and is not recommended for routine use.
Amlodipine is the only calcium channel blocker considered safe in the setting of systolic heart failure.