Mitral regurgitation resident survival guide

❑ Most preferred

❑ Done in absence of papillary muscle necrosis

Ischemic mitral regurgitation

❑ Performed in cases of complex MR with extensive tissue destruction

❑ Performed in cases of MR with lateral LV wall motion abnormality

Perform reperfusion or revascularization:

❑ In patients with acute coronary syndrome, CABG or coronary angioplasty should be performed
❑ Early reperfusion for myocardial infarction can reduce localized LV remodeling and hence MR

Perform reperfusion or revascularization:

❑ Perform CABG or coronary angioplasty at the time of mitral valve surgery in patients with myocardial infarction

Consider cardiac transplantation:
❑ On some occasions with no contraindication for surgery
❑ For patients with severe LV dysfunction

Complete Diagnostic Approach to Mitral Regurgitation

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.^[2].
Abbreviations: AF: Atrial fibrillation; MR: Mitral regurgitation; EKG: Electrocardiogram; EF: Ejection fraction; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; LV: Left ventricle; MVP: Mitral valve prolapse

Characterize the symptoms:

Acute mitral regurgitation: ❑ Symptoms of shock and pulmonary edema:

❑ Shortness of breath

❑ Orthopnea

❑ Paroxysmal nocturnal dyspnea

❑ Cough

❑ Altered mental status

❑ Pedel edema

❑ Oliguria

❑ Cyanosis

❑ Pallor

❑ Diaphoresis

❑ Abdominal pain (may be suggestive of mesenteric ischemia)

❑ Symptoms suggestive of precipitating events:

❑ Chest pain (suggestive of myocardial ischemia)

❑ Fever (suggestive of infective endocarditis)

❑ Petechiae, Osler's nodes, Janeway lesions (suggestive of infective endocarditis)

Chronic mitral regurgitation: ❑ Asymptomatic

❑ Typical in isolated mild to moderate MR

❑ Severe MR until there is left ventricular failure, pulmonary hypertension or atrial fibrillation

❑ Symptoms associated with decreased forward flow and increased backflow across mitral valve (left ventricular failure):

❑ Exertional dyspnea

❑ Orthopnea

❑ Paroxysmal nocturnal dyspnea

❑ Exercise intolerance

❑ Fatigue

❑ Light-headedness

❑ Exertional syncope

❑ Exertional angina

❑ Cough

❑ Symptoms associated with complications:

❑ Palpitations (suggestive of atrial fibrillation)

❑ Hoarseness (recurrent laryngeal nerve compression due to left atrium enlargement)

❑ Fever (suggestive of infective endocarditis)

❑ Stroke (suggestive of thromboembolism)

❑ Hemoptysis (suggestive of thromboembolism)

❑ Flank pain and hematuria (suggestive of septic emboli or glomerulonephritis)

❑ Seizures (suggestive of thromboembolism)

❑ Symptoms of right heart failure:

❑ Ascites

❑ Pedel edema

❑ Abdominal pain (hepatomegaly)

Obtain a detailed history:

❑ Past medical history:

❑ Congenital heart disease

❑ Rheumatic heart disease

❑ Ischemic heart disease

❑ Valvular heart disease

❑ Cardiomyopathy

❑ Cardiac surgery

❑ Hypertension

❑ Diabetes mellitus

❑ Radiation exposure

❑ Collagen vascular disease

❑ Chest trauma

❑ Family history:

❑ Valvular heart disease

❑ Medications:

❑ Anorectic drug combinations

❑ Ergotamine

❑ Pergolide

❑ Cabergoline

Examine the patient:

Vital signs:
❑ Pulse

❑ Rapid and thready (in acute MR)

❑ Low volume with brisk upstroke (in chronic MR)

❑ Irregularly irregular pulse (with onset of AF)

❑ Blood pressure

❑ Hypotension (in acute MR)

❑ Normotensive (in chronic MR with preserved ejection fraction)

❑ Temperature

❑ Fever (suggestive of infective endocarditis)

❑ Respiratory rate

❑ Tachypnea (typical)

Skin:
❑ Cool and clammy (in cardiogenic shock)
❑ Cyanosis
❑ Peripheral edema (suggestive of right heart failure)

Cardiovascular system:
Palpation:
❑ Apical impulse

❑ Leftward displacement (in chronic MR due enlargement of the left ventricle)

❑ Hyperdynamic but in normal location (in acute MR)

❑ Thrill (in acute MR and severe chronic MR)
❑ Elevated jugular venous pulse

❑ Sign of elevated right sided pressure

❑ Seen in acute MR and severe chronic MR

Auscultation:
❑ Heart sounds

❑ S1 is diminished (suggestive of MR)

❑ Wide splitting of S2 (low forward flow causing early A2)

❑ Loud and delayed P2 (suggestive of pulmonary hypertension)

❑ New S3 (suggestive of left ventricular dilation)

❑ Murmur

❑ High pitched and blowing holosystolic murmur (typical)

❑ Best heard over the apex radiating to the axilla and back

❑ Starts after S1 and continues up to and sometime beyond and obscuring A2

❑ Other types of murmur

❑ Silent (in cases of acute MR)

❑ Mid to late systolic murmur (in case of papillary muscle prolapse)

❑ Early diastolic murmur (due to large diastolic flow across severe MR)

❑ Mid systolic click (suggestive of mitral valve prolapse)

Respiratory system:
❑ Crackles or rales (suggestive of pulmonary edema)
❑ Tachypnea

Abdominal system:
❑ Hepatojugular reflex
❑ Hepatomegaly
❑ Ascites

Neurological system:
❑ Stroke (in case of thromboembolism)

Order electrocardiogram (urgent):

❑ In acute MR

❑ Mostly normal

❑ Findings of myocardial infarction

❑ In chronic MR

❑ Findings of left ventricular hypertrophy with strain

❑ Findings of left atrial enlargement

❑ Findings of pulmonary hypertension

❑ Findings of atrial fibrillation complication

Left atrial enlargement produces a broad, bifid P wave in lead II (**P mitrale**)

Order chest X-ray (urgent):
❑ Acute MR

❑ Normal size cardiac silhouette

❑ Signs of pulmonary edema

❑ Chronic MR

❑ Cardiomegaly

❑ Signs of pulmonary edema if left ventricle fails

❑ Calcification of the mitral valve annulus

Calcification of the mitral annulus around the margins of the posterior leaflet forming a “C”

Order transthoracic echocardiography (TTE) (urgent):
❑ Confirmatory
❑ To determine severity and assess hemodynamic consequences
❑ To establish etiology
❑ To determine prognosis and evaluate for timing of intervention

Order lab tests:
❑ CBC
❑ Electrolytes
❑ ESR
❑ Serum cardiac troponin I and T
❑ Creatine kinase (CK-MB)
❑ Blood cultures (in case of fever)
❑ Serum urea and creatinine

Other tests:
❑ Transesophageal echocardiography (TEE if TTE is equivocal)
❑ Cardiac catheterization:

❑ In stable acute MR to detect coronary obstruction

❑ To assess hemodynamic status in symptomatic patients when noninvasive tests are inconclusive

❑ To assess the severity when there is discrepancy between noninvasive testing and physical examination

❑ Exercise testing:

❑ Done in asymptomatic severe MR

❑ To confirm the absence of symptoms

❑ To assess the hemodynamic response to exercise

❑ Cardiac MRI

❑ To assess severity when there is a discrepancy between clinical findings and echocardiography

Does the patient has acute or chronic MR?

Acute MR (Cardinal findings suggestive of acute mitral regurgitation)

❑ Sudden onset and rapid progression of pulmonary edema
❑ Signs and symptoms of cardiogenic shock
❑ Silent to holosystolic murmur on auscultation
❑ Normal ECG
❑ Normal size cardiac silhouette on chest X-ray
❑ Echocardiography findings:

❑ Acute severe mitral regurgitation

❑ Normal left ventricular size

❑ Reduced EF

❑ Ruptured mitral chordae tendinae (flail leaflet)

❑ Ruptured papillary muscle

Chronic MR (cardinal findings suggestive of chronic mitral regurgitation)

❑ Asymptomatic to chronic symptoms
❑ Pre-existing heart disease
❑ Classic holosystolic murmur on auscultation
❑ ECG findings of left ventricular hypertrophy with strain and left atrial enlargement
❑ Cardiomegaly on chest X-ray
❑ Echocardiography findings:

❑ Mitral regurgitation

❑ Left ventricular dilation

❑ Preserved to decreased EF

Does the mitral valve anatomy appear normal in TTE?

Yes

No

Chronic secondary mitral regurgitation

Chronic primary mitral regurgitation

Treatment

Treatment of Acute Mitral Regurgitation

Shown below is an algorithm summarizing the approach to the management of acute mitral regurgitation.^[1]^[2].
Abbreviations: IE: Infective endocarditis; LV: Left ventricle; LVEF: Left ventricular ejection fraction; MR: Mitral regurgitation

Does the patient has any signs of hemodynamic instability?

❑ Hypotension
❑ Cold extremities
❑ Peripheral cyanosis
❑ Altered mental status

Yes

No

Initiate resuscitative measures:

❑ Secure airway
❑ Administer O2
❑ Establish 2 wide bore IV access
❑ Establish an arterial line
❑ Connect to ECG monitor
❑ Monitor vitals continuously
❑ Consider ICU admission
❑ Consider mechanical ventilation
❑ Consider pulmonary artery catheterization

Stabilize the patient:
❑ Initiate medical stabilization:

❑ Vasodilator (IV nitroprusside) PLUS inotropic agents (IV dobutamine)

❑ Establish intra-aortic balloon pump:

❑ If medical therapy is not effective to maintain hemodynamic stability

Initiate resuscitative measures:

❑ Administer O2
❑ Establish 2 wide bore IV access
❑ Connect to ECG monitor
❑ Monitor vitals continuously

Initiate medical therapy:

❑ Vasodilator therapy: IV nitroprusside

MR due to IE (organic MR)

MR due to heart failure exacerbation(functional MR)

Initiate IE medical therapy:

❑ Click here for infective endocarditis resident survival guide and antimicrobial treatment

Perform reperfusion or revascularization surgery:

❑ CABG or coronary angioplasty should be done to treat acute coronary syndrome
❑ Early reperfusion can reduce localized LV remodeling and hence MR

Initiate treatment for heart failure:

❑ Click here for acute heart failure resident survival guide

❑ ACE inhibitors or (ARBs) if LVEF is ≤ 40%

❑ Intravenous inotropic drugs (dobutamine)

❑ Diuretic therapy

❑ IV vasodilators

Does the patient has any indications for mitral valve surgery?

❑ Hemodynamic instability
❑ Persistent heart failure
❑ Pulmonary hypertension

❑ Early mitral valve closure

Does the patient has any indications for mitral valve surgery?

❑ Papillary muscle rupture
❑ Chordae tendinae rupture

❑ Moderate to severe ischemic MR who are undergoing CABG

Does the patient show any hemodynamic improvement to medical therapy?

Yes

No

Yes

No

Yes

No

Perform mitral valve surgery:

❑ Mostly done

❑ Due to extensive tissue destruction in IE patients

❑ Angiotensin converting enzyme inhibitors

❑ If less mitral valve destruction

❑ Continue with medical management

Perform mitral valve surgery:

❑ Done at the time of reperfusion
❑ Mitral valve repair:

❑ Most preferred

❑ Mitral valve replacement: Preferred in the following groups

❑ In centers with surgeons who do not have expertise in mitral valve repair techniques

❑ Very ill patients presenting after an acute MI

❑ Complex MR

❑ In cases of lateral LV wall motion abnormality

Consider medical therapy:
❑ In cases of reduced LVEF (ischemic cardiomyopathy)
❑ Medications:

❑ Angiotensin II receptor blockers

Consider cardiac transplantation:
❑ On some occasions in patients with severe LV dysfunction with no contraindication for surgery

Continue with the heart failure management and have appropriate follow ups to assess the severity of MR

Consider mitral valve surgery:

❑ Most preferred

❑ In centers with surgeons who do not have expertise in mitral valve repair techniques

❑ In cases of lateral LV wall motion abnormality

Initiate anticoagulation therapy:

❑ For patients undergoing mitral valve replacement
❑ Warfarin: Target INR 3
❑ Aspirin: 75 to 100 mg/day

Educate the patient about IE prophylaxis:
❑ For all patients
❑ Indicated for the following procedures:

Initiate anticoagulation therapy:

❑ For patients undergoing mitral valve replacement
❑ Warfarin: Target INR 3
❑ Aspirin: 75 to 100 mg/day

Educate the patient about IE prophylaxis:
❑ For patients who undergo mitral valve replacement
❑ Indicated for the following procedures:

Initiate anticoagulation therapy:

❑ For patients undergoing mitral valve replacement
❑ Warfarin: Target INR 3
❑ Aspirin: 75 to 100 mg/day

Educate the patient about IE prophylaxis:
❑ For patients who undergo mitral valve replacement
❑ Indicated for the following procedures:

Treatment of Chronic Mitral Regurgitation

Chronic Primary Mitral Regurgitation

Shown below is an algorithm summarizing the approach to the management of chronic primary mitral regurgitation.^[2].
Abbreviations: AF: Atrial fibrillation; IE: Infective endocarditis; LVEF: Left ventricular ejection fraction; LVESD: Left ventricular end systolic dimension; MR: Mitral regurgitation; MVP: Mitral valve proplapse; PASP: Pulmonary artery systolic pressure; RHD: Rheumatic heart disease

Determine the severity of MR on TTE

Severe MR:

❑ Severe MVP with loss of coaptation
❑ RHD with loss of central coaptation
❑ Left ventricular dilation
❑ Regurgitation fraction ≥ 50%
❑ Regurgitation volume ≥ 60ml
❑ Effective regurgitation orifice ≥ 0.4cm²
❑ Vena contracta ≥ 0.7cm

Progressive MR (Stage B):

❑ Severe MVP with normal coaptation
❑ RHD with normal coaptation
❑ No Left ventricular dilation
❑ Regurgitation fraction < 50%
❑ Regurgitation volume < 60ml
❑ Effective regurgitation orifice < 0.4cm²
❑ Vena contracta < 0.7cm

Symptomatic (Stage D)

Asymptomatic (Stage C)

Does the patient has any indications for mitral valve surgery?

❑ LVEF 30 to ≤60% OR LVESD ≥ 40mm (Stage C2)
❑ LVEF >60% AND LVESD < 40mm (Stage C1)

❑ With likelihood of successful repair > 95%

❑ With expected mortality < 1%

❑ New onset AF OR PASP > 50mmHg (Stage C1)

❑ With likelihood of successful repair > 95%

❑ With expected mortality < 1%

Yes

No

Initiate medical therapy:

❑ Vasodialators:

❑ Intravenous nitroprusside

❑ Hydralazine

❑ Beta blocker
❑ Diuretics
❑ Calcium channel blocker

Perform mitral valve surgery:
❑ Mitral valve repair:

❑ Mostly preferred

❑ In centers with surgeons who do not have expertise in mitral valve repair techniques

❑ Mechanical valve in patients <65 years who have long-standing AF

❑ Bioprosthetic valves in patients with contraindications to warfarin

Perform revascularisation:
❑ In cases with concurrent coronary artery disease
❑ Revascularized at the time of mitral valve surgery

Perform mitral valve surgery:

❑ Mostly preferred

❑ In centers with surgeons who do not have expertise in mitral valve repair techniques

❑ Mechanical valve in patients <65 years who have long-standing AF

❑ Bioprosthetic valves in patients with contraindications to warfarin

Perform revascularization:
❑ For patients with concurrent coronary artery disease
❑ Revascularized at the time of mitral valve surgery

Periodic monitoring:
❑ In stage C1 patients with the following:

❑ With likelihood of successful repair < 95%

❑ With expected mortality > 1%

❑ Clinical evaluation:

❑ Every 3-6 months

❑ Every 6 months

Periodic monitoring:

❑ Clinical evaluation:

❑ Every 3-6 months

❑ Every 6 months

Initiate anticoagulation therapy:

❑ Indications:

❑ Rheumatic mitral valve disease who have a history of systemic embolism

❑ Left atrial thrombus

❑ Paroxysmal or chronic atrial fibrillation

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)

❑ Target INR 3 (for prosthetic valve)

❑ Aspirin:

❑ 75 to 100 mg/day

❑ For patients with recurrent embolism despite adequate anticoagulation

❑ For patients with prosthetic valve

Educate the patient about IE prophylaxis:
❑ For patients who undergo mitral valve replacement
❑ Indicated for the following procedures:

Initiate anticoagulation therapy:

❑ Indications:

❑ Rheumatic mitral valve disease who have a history of systemic embolism

❑ Left atrial thrombus

❑ Paroxysmal or chronic atrial fibrillation

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)

❑ Target INR 3 (for prosthetic valve)

❑ Aspirin:

❑ 75 to 100 mg/day

❑ For patients with recurrent embolism despite adequate anticoagulation

❑ For patients with prosthetic valve

Educate the patient about IE prophylaxis:
❑ For patients who undergo mitral valve replacement
❑ Indicated for the following procedures:

Initiate anticoagulation therapy:

❑ Indications:

❑ Rheumatic mitral valve disease who have a history of systemic embolism

❑ Left atrial thrombus

❑ Paroxysmal or chronic atrial fibrillation

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)

❑ Target INR 3 (for prosthetic valve)

❑ Aspirin:

❑ 75 to 100 mg/day

❑ For patients with recurrent embolism despite adequate anticoagulation

❑ For patients with prosthetic valve

Chronic Secondary Mitral Regurgitation

Shown below is an algorithm summarizing the approach to the management of chronic secondary mitral regurgitation.^[2].

Abbreviations: AF: Atrial fibrillation; CAD: Coronary artery disease; HF: Heart failure; IE: Infective endocarditis; LV: Left ventricle; MR: Mitral regurgitation

Determine the etiology and initiate specific treatment

Heart failure:

❑ Click here for heart failure resident survival guide

❑ ACE inhibitors

❑ ARBs

❑ Intravenous inotropic drugs (dobutamine)

❑ Diuretic therapy

❑ IV vasodilators

Coronary artery disease:

❑ Click here for coronary artery disease medical therapy

❑ Aspirin

❑ ACE inhibitors

❑ Coronary angiography
❑ Click here for revascularization therapy

Functional MR with ventricular dyssynchrony:

❑ Cardiac resynchronization therapy with biventricular pacing:

❑ To reduce LV end-systolic and end-diastolic dimensions

❑ To reduce mitral regurgitant jet area

Assess the severity of MR on TTE

Severe MR:

❑ Regional wall motion abnormalities with severe tethering of mitral leaflet
❑ Annular dilation with severe loss of central coaptation of the mitral leaflets
❑ LV dilation and systolic dysfunction due to primary myocardial disease
❑ Regurgitation fraction ≥ 50%
❑ Regurgitation volume ≥ 30ml
❑ Effective regurgitation orifice ≥ 0.2 cm²

Progressive MR:

❑ Regional wall motion abnormalities with mild tethering of mitral leaflets
❑ Annular dilation with mild loss of central coaptation of the mitral leaflets
❑ LV dilation and systolic dysfunction due to primary myocardial disease
❑ Regurgitation fraction < 50%
❑ Regurgitation volume < 30ml
❑ Effective regurgitation orifice < 0.2 cm²

Does the HF symptoms due to MR persist even after revascularization and medical therapy?

HF and coronary ischemia symptoms respond to revascularization and medical herapy

Yes (Stage D)

No (Stage C)

Stage B

Perform mitral valve surgery:

❑ Mostly preferred

❑ In centers with surgeons who do not have expertise in mitral valve repair techniques

❑ Mechanical valve in patients <65 years who have long-standing AF

❑ Bioprosthetic valves in patients with contraindications to warfarin

Periodic monitoring:

❑ Clinical evaluation:

❑ Every 3-6 months

❑ Every 6 months

Consider mitral valve surgery:
❑ Only for patients undergoing other cardiac surgery

Periodic monitoring:

❑ Clinical evaluation:

❑ Every 3-6 months

❑ Every 6 months

Consider mitral valve surgery:
❑ Only for patients undergoing other cardiac surgery

Initiate anticoagulation therapy:

❑ Indications:

❑ History of systemic embolism

❑ Left atrial thrombus

❑ Paroxysmal or chronic atrial fibrillation

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)

❑ Target INR 3 (for prosthetic valve)

❑ Aspirin:

❑ 75 to 100 mg/day

❑ For patients with recurrent embolism despite adequate anticoagulation

❑ For patients with prosthetic valve

Educate the patient about IE prophylaxis:
❑ For patients who undergo mitral valve replacement
❑ Indicated for the following procedures: