Footnotes Conflict of interest: Dr Fine serves on the Board of Directors of the American Academy of Pain Medicine and ISA Scientific. Dr Rosenfeld serves on the Board of Directors of ISA

Scientific.
Mitral valve regurgitation (MR) is the most prevalent valvular heart disease in the community, its prevalence increasing along with population aging and heart failure.1 Inhibitors,research,lifescience,medical Etiology of MR can be very diverse, and the mechanism of regurgitation is variable according to the underlying anatomo-functional lesions. Organic lesions are most commonly secondary to degeneration of connective tissue with localized or diffuse alterations of the annulus, leaflets, and chordae, leading to prolapsing lesions and annular dilatation. Beyond degenerative MR (DMR), organic MR can be of Inhibitors,research,lifescience,medical post-inflammatory, infective etiology, or associated to other rare diseases. In contrast, functional MR (FMR) is characterized by absence of structural lesions, and mitral insufficiency is due to sub-valvular and valvular deformations caused by left ventricular remodeling and dysfunction.2 The natural history of severe MR is unfavorable, leading to left ventricular (LV) failure, atrial fibrillation, Inhibitors,research,lifescience,medical stroke, and death.3 Conventional treatment of significant MR is surgery, either repair or replacement. This is particularly true for DMR. Surgery for DMR is very safe

and effective, and, in relatively young patients with few co-morbidities, MEK162 novartis hospital mortality is below 1%.4 As a consequence, the current approach is to perform Inhibitors,research,lifescience,medical early surgery with mitral valve reconstruction to guarantee preservation of life expectancy and quality of life similar to a comparable healthy population.5

On the other hand, the landscape of FMR therapies is wide and full of controversies. Functional MR is dependent on loading conditions, and timing of surgery can be difficult to establish, particularly when patients are evaluated under aggressive therapy and in resting conditions.6 Surgery for FMR carries higher risk compared to DMR, and its prognostic value as well as the best surgical treatment for functional MR is still debated.7,8 Inhibitors,research,lifescience,medical As an alternative to surgery, FMR can be selleck chemical managed with medical therapy GSK-3 or other therapies acting on left ventricular function including resynchronization. The Euro Heart Survey data9 revealed that up to 50% of symptomatic patients hospitalized with severe MR are not referred for surgery, mainly due to advanced age (>70 years), co-morbidities, and depressed LV function, so that the surgical risk is considered too high. In the subgroup of patients aged 80 years and older, surgical treatment was performed only in 15%, as compared to 60% in patients aged 70 years and younger. Data from the Society of Thoracic Surgeons (STS) database confirm that surgical risk increases with age, and it is higher for replacement and in combined procedures involving coronary artery bypass grafting.10,11 Badhwar et al.