Mitral regurgitation resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S. [2]; Mugilan Poongkunran M.B.B.S [3]

Mitral Regurgitation Resident Survival Guide Microchapters
Overview
Causes
FIRE
Complete Diagnostic Approach
Treatment
Acute MR
Chronic MR
Do's
Don'ts

Overview

Mitral regurgitation (MR), mitral insufficiency or mitral incompetence refers to a disorder of the heart in which the mitral valve fails to close properly during systole. This leads to leakage of blood flow from left ventricle to left atrium during systole and reduction in cardiac output. The symptoms associated with mitral regurgitation are dependent on which phase of the disease process the individual is in. Individuals with acute mitral regurgitation are often gravely ill with significant hemodynamic abnormalities due to decompensated congestive heart failure and low cardiac output that require urgent treatment, whereas individuals with chronic compensated mitral regurgitation may be asymptomatic, with a normal exercise tolerance and no evidence of heart failure.[1] The management of chronic MR depends on whether the condition is chronic primary MR (the mitral valve is usually abnormal) or chronic secondary MR (the mitral valve is usually normal) and the severity of the valve anatomy.[2]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Acute Mitral Regurgitation

Chronic Primary Mitral Regurgitation

Chronic Secondary Mitral Regurgitation


Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in salmon colour signify that an urgent management is needed



 
 
 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of mitral regurgitation:

❑ Murmur:

❑ High pitched and blowing holosystolic murmur (typical)
❑ Best heard over the apex radiating to the axilla and back

❑ Heart sounds:

❑ S1 is diminished (suggestive of MR)
❑ Wide splitting of S2 (low forward flow causing early A2)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings of acute mitral regurgitation?

❑ Sudden onset and rapid progression of pulmonary edema:

❑ Shortness of breath
❑ Tachypnea
❑ Crackles or rales

❑ Signs and symptoms of cardiogenic shock

❑ Altered mental status
❑ Oliguria
❑ Cyanosis
❑ Diaphoresis
❑ Tachycardia
❑ Hypotension
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue with complete diagnostic approach below
 
 
 
 
 
 
 
 
 
Initial resusticative measures:

❑ Secure airway
❑ O2
❑ 2 wide bore IV access
❑ Arterial line

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

Initiate medical therapy:

❑ Vasodilator therapy

❑ Nitroprusside

AND
❑ Inotropic agents

❑ Dobutamine

Consider the following:

❑ Mechanical ventilation

❑ Pulmonary artery catheterization
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ischemic mitral regurgitation:

Intra-aortic balloon pump

Initiate medical therapy:

❑ In cases of reduced LVEF
❑ Medications:

❑ Angiotensin converting enzyme inhibitors
❑ Angiotensin II receptor blockers
❑ Beta blockers

Reperfusion or revascularization

Mitral valve surgery:

❑ Papillary muscle rupture
❑ Moderate to severe ischemic MR who are undergoing CABG
❑ Mitral valve repair:

❑ Most preferred
❑ Done in absence of papillary muscle necrosis

❑ Mitral valve replacement:

❑ In complex MR with extensive destruction
❑ Lateral LV wall motion abnormality

Cardiac transplantation:

❑ On some occasions with no contraindication for surgery
❑ In patients with severe LV dysfunction

 
MR due to cardiomyopathy:

Heart failure management:

❑ Click here for acute heart failure resident survival guide

❑ ACE inhibitors or (ARBs) if LVEF is ≤ 40%
❑ Beta blockers
❑ Intravenous inotropic drugs (dobutamine)
❑ Diuretic therapy
❑ IV vasodilators

Mitral valve surgery:

❑ When there is no response to medical management

❑ Mitral valve replacement or mitral valve repair
 
MR due to infective endocarditis:

Mitral valve surgery:

❑ Mitral valve replacement:

❑ Mostly done
❑ Due to extensive tissue destruction

❑ Mitral valve repair:

❑ If less mitral valve destrcution

Initiate medical therapy:

❑ Infective endocarditis antimicrobial treatment

 
 
 
 
 

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. Shown below is an algorithm summarizing the complete diagnostic approach to mitral regurgitation according to 2014 AHA/ACC guidelines for management of valvular heart disease.[2].
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:

❑ 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)

❑Other etiology associated symptoms:

❑ Joint pains (suggestive of rheumatic etiology)
❑ Skin lesions (suggestive of rheumatic etiology)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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

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

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 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardinal findings that are 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
 
 
 
 
 
Cardinal findings that are 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mitral valve anatomy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
Abnormal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic primary mitral regurgitation
 
Chronic secondary 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].
LVEF: Left ventricular ejection fraction; MR: Mitral regurgitation; IE: Infective endocarditis

 
 
 
 
 
 
 
Acute mitral regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess if the patient is hemodynamically stable?

❑ Hemodynamic instability

❑ Hypotension
❑ Cold extremities
❑ Peripheral cyanosis
❑ Altered mental status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial resusticative measures:

❑ Secure airway
❑ O2
❑ 2 wide bore IV access
❑ Arterial line

Initiate medical therapy:

❑ Vasodilator therapy

❑ Nitroprusside

AND
❑ Inotropic agents

❑ Dobutamine

Consider the following:

❑ Mechanical ventilation

❑ Pulmonary artery catheterization
 
 
 
Initial resusticative measures:

❑ O2
❑ 2 wide bore IV access
❑ Arterial line

Initiate medical therapy:

❑ Vasodilator therapy

❑ Nitroprusside
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ischemic mitral regurgitation
 
 
 
Non-ischemic mitral regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MR due to cardiomyopathy (functional MR)
 
MR due to IE (organic MR)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intra-aortic balloon pump

Initiate medical therapy:

❑ In cases of reduced LVEF
❑ Medications:

❑ Angiotensin converting enzyme inhibitors
❑ Angiotensin II receptor blockers
❑ Beta blockers

Reperfusion or revascularization

Mitral valve surgery:

❑ Papillary muscle rupture
❑ Moderate to severe ischemic MR who are undergoing CABG
❑ Mitral valve repair:

❑ Most preferred
❑ Done in absence of papillary muscle necrosis

❑ Mitral valve replacement:

❑ In complex MR with extensive destruction
❑ Lateral LV wall motion abnormality

Cardiac transplantation:

❑ On some occasions with no contraindication for surgery
❑ In patients with severe LV dysfunction

 
Heart failure management:

❑ Click here for acute heart failure resident survival guide

❑ ACE inhibitors or (ARBs) if LVEF is ≤ 40%
❑ Beta blockers
❑ Intravenous inotropic drugs (dobutamine)
❑ Diuretic therapy
❑ IV vasodilators

Mitral valve surgery:

❑ When there is no response to medical management

❑ Mitral valve replacement or mitral valve repair
 
Mitral valve surgery:

❑ Mitral valve replacement:

❑ Mostly done
❑ Due to extensive tissue destruction

❑ Mitral valve repair:

❑ If less mitral valve destrcution

Initiate medical therapy:

❑ Infective endocarditis antimicrobial treatment

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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].
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;

 
 
 
 
 
 
Chronic primary mitral regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe MR:

❑ Etiologies:

❑ Severe MVP with loss of coaptation
❑ RHD with loss of central coaptation
❑ Prior IE
❑ Radiation induced leaflet thickening

❑ Left ventricular dilation
❑ Regurgitation fraction ≥ 50%
❑ Regurgitation volume ≥ 60ml
❑ Effective regurgitation orifice ≥ 0.4cm²
❑ Vena contracta ≥ 0.7cm

 
 
 
Progressive MR (Stage B):

❑ Etiologies:

❑ Severe MVP with normal coaptation
❑ RHD with loss of central coaptation
❑ Prior IE

❑ 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)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initiate medical therapy:

❑ Vasodialators:

❑ Intravenous nitroprusside
❑ Hydralazine

❑ Beta blocker
❑ Diuretics
❑ Calcium channel blocker

Mitral valve surgery:

❑ Mitral valve repair:

❑ Mostly preferred

❑ Mitral valve replacement:

❑ Mechanical valve in patients <65 years who have long-standing AF
❑ Bioprosthetic valves in patients with contraindications to warfarin

Revascularisation:

❑ Concurrent coronary artery disease
❑ Revascularized at the time of mitral valve surgery

Anticoagulation therapy:

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)
❑ Rheumatic mitral valve disease who have a history of systemic embolism
❑ Left atrial thrombus
❑ Paroxysmal or chronic atrial fibrillation

❑ Aspirin:

❑ 75 to 100 mg/day
❑ Recurrent embolism despite adequate anticoagulation

Endocarditis prophylaxis:

❑ Initiate infective endocarditis antimicrobial treatment

 
Mitral valve surgery:

❑ Performed in the following patients:

❑ 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%

❑ Mitral valve repair:

❑ Mostly preferred

❑ Mitral valve replacement:

❑ Mechanical valve in patients <65 years who have long-standing AF
❑ Bioprosthetic valves in patients with contraindications to warfarin

Revascularization:

❑ 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%

❑ Echocardiography:

❑ Every 6 months

Anticoagulation therapy:

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)
❑ Rheumatic mitral valve disease who have a history of systemic embolism
❑ Left atrial thrombus
❑ Paroxysmal or chronic atrial fibrillation

❑ Aspirin:

❑ 75 to 100 mg/day
❑ Recurrent embolism despite adequate anticoagulation

Endocarditis prophylaxis:

❑ Initiate infective endocarditis antimicrobial treatment

 
Periodic monitoring:

❑ Clinical evaluation:

❑ Every 3-6 months

❑ Echocardiography:

❑ Every 6 months

Anticoagulation therapy:

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)
❑ Rheumatic mitral valve disease who have a history of systemic embolism
❑ Left atrial thrombus
❑ Paroxysmal or chronic atrial fibrillation

❑ Aspirin:

❑ 75 to 100 mg/day
❑ Recurrent embolism despite adequate anticoagulation

Endocarditis prophylaxis:

❑ Initiate infective endocarditis antimicrobial treatment in case of valve involvement

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Chronic Secondary Mitral Regurgitation

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

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic secondary mitral regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Heart failure treatment:

❑ Click here for heart failure resident survival guide

❑ ACE inhibitors
❑ ARBs
❑ Beta blockers
❑ Intravenous inotropic drugs (dobutamine)
❑ Diuretictherapy
❑ IV vasodilators
 
CAD treatment:

❑ Click here for coronary artery disease medical therapy

❑ Aspirin
❑ ACE inhibitors
❑ Beta blockers

❑ Coronary angiography
❑ Click here for revascularization therapy

 
Cardiac resynchronization therapy:

❑ Cardiac resynchronization therapy with biventricular pacing:

❑ In functional MR patients with ventricular dyssynchrony
❑ Reduce LV end-systolic and end-diastolic dimensions
❑ Reduce mitral regurgitant jet area
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe MR:

❑ Echo findings:

❑ 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 (Stage B):

❑ Echo findings:

❑ Regional wall motion abnormalities with mild tethering of mitral leaflet
❑ 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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage D: Symptomatic (HF symptoms due to MR persist even after revascularization and medical therapy)
 
Stage C: Asymptomatic (HF and coronary ischemia symptoms respond to revascularization and medical herapy)
 
HF and coronary ischemia symptoms respond to revascularization and medical herapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mitral valve surgery:

❑ Mitral valve repair:

❑ Mostly preferred

❑ Mitral valve replacement:

❑ Mechanical valve in patients <65 years who have long-standing AF
❑ Bioprosthetic valves in patients with contraindications to warfarin

Anticoagulation therapy:

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)
❑ History of systemic embolism
❑ Left atrial thrombus
❑ Paroxysmal or chronic atrial fibrillation

❑ Aspirin:

❑ 75 to 100 mg/day
❑ Recurrent embolism despite adequate anticoagulation

Endocarditis prophylaxis:

❑ Initiate infective endocarditis antimicrobial treatment

 
Periodic monitoring:

❑ Clinical evaluation:

❑ Every 3-6 months

❑ Echocardiography:

❑ Every 6 months

Mitral valve surgery:

❑ Only in patients undergoing other cardiac surgery
❑ Mitral valve repair:

❑ Mostly preferred

❑ Mitral valve replacement:

❑ Mechanical valve in patients <65 years who have long-standing AF
❑ Bioprosthetic valves in patients with contraindications to warfarin

Anticoagulation therapy:

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)
❑ History of systemic embolism
❑ Left atrial thrombus
❑ Paroxysmal or chronic atrial fibrillation

❑ Aspirin:

❑ 75 to 100 mg/day
❑ Recurrent embolism despite adequate anticoagulation

Endocarditis prophylaxis:

❑ Initiate infective endocarditis antimicrobial treatment for patients undergoing mitral valve surgery

 
Periodic monitoring:

❑ Clinical evaluation:

❑ Every 3-6 months

❑ Echocardiography:

❑ Every 6 months

Mitral valve surgery:

❑ Only in patients undergoing other cardiac surgery
❑ Mitral valve repair:

❑ Mostly preferred

❑ Mitral valve replacement:

❑ Mechanical valve in patients <65 years who have long-standing AF
❑ Bioprosthetic valves in patients with contraindications to warfarin

Anticoagulation therapy:

❑ Warfarin:

❑ Target INR 2.5 (range 2.0 to 3.0)
❑ History of systemic embolism
❑ Left atrial thrombus
❑ Paroxysmal or chronic atrial fibrillation

❑ Aspirin:

❑ 75 to 100 mg/day
❑ Recurrent embolism despite adequate anticoagulation

Endocarditis prophylaxis:

❑ Initiate infective endocarditis antimicrobial treatment for patients undergoing mitral valve surgery

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Diagnosis

Symptoms

  • Chronic mitral regurgitation may have a prolonged asymptomatic interval phase until the heart decompensates and the symptoms of low cardiac output and pulmonary congestion start. By the time the symptoms develop, left ventricular dysfunction may have already occurred.

Physical Examination

  • S3 and S4 may be heard on auscultation.
  • A holosystolic murmur is heard in the apical region of the heart. MR murmur radiates to the axillary region. It may be soft, short and even absent. 70% of the cases of papillary muscle rupture have no murmur.
Holosystolic murmur of acute mitral regurgitation.
Holosystolic murmur of chronic mitral regurgitation.

Imaging

Transthoracic echocardiography

Echocardiographic findings indicating the presence of severe mitral regurgitation include:

  • Regurgitant volume >60 ml
  • Regurgitant fraction >55%
  • Effective regurgitant orifice (ERO) (ratio of regurgitant flow volume to the velocity of the mitral insufficiency jet: ERO = Flow / Velocity) >0.4 cm2
  • If the left ventricular and left atrial sizes are normal on echocardiography, mitral regurgitation is not severe.
  • Central jets indicate the presence of a fairly normal mitral valve and therefore the mitral regurgitation is not severe.
  • Wide eccentric jets indicate that the regurgitation is severe.
  • Echocardiographic findings must match the symptoms, if they do not, perform transesophageal echocardiography (TEE) or cardiac catheterization. TTE can underestimate the magnitude of mitral regurgitation in patients with clinical signs of severe MR.

Treatment

Acute Severe Mitral Regurgitation

  • If the patient is clinically unstable , the treatment options are:
    • IV nitroprusside is used to maintain blood pressure. Inotropes are added when needed.
    • If medical therapy is not effective, an intra aortic balloon pump can be inserted to maintain hemodynamic stability.
    • Surgical treatment is usually indicated.
    • Knowledge of the etiology of the mitral regurgitation is important to know if the valve can be repaired or replaced.

Chronic Mitral Regurgitation

Why the Mitral valve is replaced Before Symptoms in Patients with Chronic Mitral Regurgitation

  • Mitral regurgitation is a syndrome of pure volume overload whereas aortic regurgitation is a combination of both volume and pressure overload.
  • Both syndromes are associated with an increase in preload.
  • in mitral regurgitation, the afterload is reduced whereas in aortic regurgitation the afterload is increased. This is very important because when the mitral valve is repaired, there is no longer a reduction afterload and the left ventricle may fail due to an abrupt rise in the afterload. In aortic regurgitation, because the afterload is already increased chronically, replacement of the valve is not as likely to precipitate acute left ventricular failure due to an abrupt rise in afterload.
  • By the time symptoms develop, there is already left ventricular dysfunction.
  • Because of the low pressure system into which the blood is ejected into through the mitral valve, the ejection fraction is always high in mitral regurgitation. If the ejection fraction appears to be "normal", there is already decline in left ventricular function.
  • There is no indication for vasodilator therapy in the absence of systemic hypertension in asymptomatic patients with preserved left ventricular function.

Indications for Surgery in Chronic Mitral Regurgitation

The indications for surgery in chronic mitral regurgitation are:

  • Any symptoms - this is unlike mitral stenosis where surgeons operate on the heart when patients have class III or IV symptoms.
  • Severe organic MR.
  • Left ventricular dysfunction - ejection fraction <60% and end systolic diameter >40 mm2.
  • Surgery can be considered in asymptomatic patients in the following cases:
    • Truly severe MR
    • Low operative mortality
    • High chance of successful repair (e.g: posterior leaflet - MVP)
  • Pre-operative ejection fraction has a prognostic impact in patients who undergo mitral valve repair or replacement. The lower the ejection fraction is, the higher the mortality is.

Do's

Don'ts


References

  1. ↑ 1.0 1.1 Stout KK, Verrier ED (2009). "Acute valvular regurgitation". Circulation. 119 (25): 3232–41. doi:10.1161/CIRCULATIONAHA.108.782292. PMID 19564568.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  3. ↑ Grenadier E, Alpan G, Keidar S, Palant A (1983). "The prevalence of ruptured chordae tendineae in the mitral valve prolapse syndrome". Am Heart J. 105 (4): 603–10. PMID 6837414.
  4. ↑ Grinberg AR, Finkielman JD, Piñeiro D, Festa H, Cazenave C (1998). "Rupture of mitral chorda tendinea following blunt chest trauma". Clin Cardiol. 21 (4): 300–1. PMID 9580528.
  5. ↑ Anderson Y, Wilson N, Nicholson R, Finucane K (2008). "Fulminant mitral regurgitation due to ruptured chordae tendinae in acute rheumatic fever". J Paediatr Child Health. 44 (3): 134–7. doi:10.1111/j.1440-1754.2007.01214.x. PMID 17854408.
  6. ↑ Otto CM (2001). "Clinical practice. Evaluation and management of chronic mitral regurgitation". N Engl J Med. 345 (10): 740–6. doi:10.1056/NEJMcp003331. PMID 11547744.


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