Acute mitral regurgitation treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Acute mitral regurgitation secondary to left ventricular papillary muscle rupture or chordae tendineae rupture, is a medical and surgical emergency. Patients may present with acute pulmonary edema or cardiogenic shock and most often the required and definitive treatment is valvular surgery. However, medical therapy may be needed to stabilize the patient until surgery can be performed.
Medical Therapy
The main treatment of acute mitral regurgitation is urgent surgery. Medical therapy should be provided to stabilize the patient during the diagnostic work up and before surgery. Surgery should not be delayed.
- Vasodilators, such as nitroprusside or nicardipine, may be of use in acute MR to decrease the afterload and thereby decrease the regurgitant fraction. However, the use of vasodilators is limited by hypotension.[1][2] ACE inhibitors may be useful as oral therapy.
- Prior to the surgical procedure, an intra-aortic balloon pump may be placed in order to improve perfusion of the organs and to reduce afterload and thereby decrease the degree of mitral regurgitation.[3]
- Among patients with hemodynamic compromise, percutaneous circulatory assist device can also be used to stabilize the patient before surgery.
- In patients with acute mitral regurgitation secondary to myocardial ischemia/infarction, early coronary revascularization should be performed.
Surgery
Surgery is the main treatment of symptomatic acute severe primary mitral regurgitation and it should be performed urgently without any delay. Although some patients with moderate acute MR develop some compensatory mechanisms, surgery remains the treatment of choice for the majority of patients with acute MR.
In comparison to elective surgeries, the mortality rate is higher in emergency mitral valve surgery with a mortality rate of 23% at 30 days following surgery.[4] There was no difference in mortality between mitral valve repair or mitral valve replacement.
The choice between mitral valve repair and mitral valve replacement depends upon the etiology and extent of the valvular damage.
- Patients with rupture of the chordae tendineae should preferably undergo early mitral valve repair if possible because it associated with less operative mortality and better lon-term survival in comparison to mitral valve replacement.
- Infective Endocarditis: The choice of the valvular surgery depends on the extent of destruction of the mitral valve. When possible, mitral valve repair is the preferred surgical approach.
In patients with acute mitral regurgitation due to endocarditis, early valve replacement surgery during hospitalization is recommended in the following conditions:[5][6]
- Heart failure due to the valve dysfunction (Class I, level of evidence B)
- Left sided infective endocarditis due to staphylococcus aureus, fungal or highly resistant organisms (Class I, level of evidence B)
- Heart block, annular or aortic abscess or destructive lesions (Class I, level of evidence B)
- Persistent bacteremia or fever 5 to 7 following the initiation of the antibiotics (Class I, level of evidence B)
- Relapse of the infection depsite a complete course of antibiotics in prosthetic valve endocarditis when no portal of infection can be identified (Class I, level of evidence C)
- Recurrent emboli and persistent vegetations despite antibiotic therapy (Class IIa, level of evidence B)
- Mobile vegetations with a length more than 10 mm in native valve endocarditis(Class IIb, level of evidence B)
In the absence of these conditions, elective surgery may be appropriate.
References
- ↑ Chatterjee K, Parmley WW, Swan HJ, Berman G, Forrester J, Marcus HS (1973). "Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus". Circulation. 48 (4): 684–90. PMID 4744778. Retrieved 2011-03-18. Unknown parameter
|month=ignored (help) - ↑ Harshaw CW, Grossman W, Munro AB, McLaurin LP (1975). "Reduced systemic vascular resistance as therapy for severe mitral regurgitation of valvular origin". Annals of Internal Medicine. 83 (3): 312–6. PMID 1180426. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-03-18. Unknown parameter
|month=ignored (help) - ↑ Lorusso R, Gelsomino S, De Cicco G, Beghi C, Russo C, De Bonis M, Colli A, Sala A (2008). "Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study". European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery. 33 (4): 573–82. doi:10.1016/j.ejcts.2007.12.050. PMID 18313322. Retrieved 2011-03-18. Unknown parameter
|month=ignored (help) - ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
- ↑ Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter
|month=ignored (help)