Mitral Regurgitation Follow-up

  • Author: Ivan Hanson, MD; Chief Editor: Richard A Lange, MD   more...
 
Updated: Oct 7, 2011
 

Complications

  • Medical complications
    • Pulmonary edema
    • Congestive heart failure
    • Irreversible LV systolic dysfunction
    • Thromboembolism resulting from atrial fibrillation
  • Surgical complications
    • Operative risks include infection, bleeding, intraoperative myocardial infarction, and stroke.
    • In young patients, bioprosthetic valves (ie, porcine valves) have a propensity for early degeneration due to calcification.
    • Mechanical valve complications include prosthetic valve dysfunction and valve thrombosis with or without embolism, particularly in the patient who is not adequately anticoagulated.
    • Hemolysis may occur in the patient with a ball and cage mechanical valve because of mechanical valve destruction of circulating red blood cells. Hemolysis in the patient with a tilting disk valve usually indicates the presence of a perivalvular leak.
    • Thromboembolism in patients with mechanical valves who are on anticoagulation therapy occurs at a rate of 1-3% per year.
    • In the absence of anticoagulation, thromboembolism occurs at a rate of approximately 1.5% per year with a porcine valve.
    • Prosthetic valve infection may occur in bioprosthetic or mechanical valves.
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Prognosis

  • Asymptomatic chronic severe degenerative MR
    • Mortality ranges from 50-73% at 5 years.
    • Mortality in patients with preserved LV function ranges from 27-45%.
    • Sudden death may be as common as 1-8% per year in patients with a flail leaflet.
  • Functional MR: In a study of patients with low EF (regardless of ischemic or nonischemic etiology), the presence of functional MR is associated with a 2-fold greater risk of all-cause mortality and hospitalization at 1-5 years.[7]
  • Mitral valve surgery operative mortality
    • Isolated mitral valve repair surgery carries a 2% mortality.
    • Mitral valve replacement surgery
      • 4% mortality for patients younger than 50 years.
      • 17% mortality for patients older than 80 years.
  • Tribouilloy et al found that, in patients with organic mitral regurgitation (MR) due to flail leaflets, left ventricular end-systolic diameter (LVESD) is independently associated with increased mortality. Analysis of results in 739 patients showed that LVESD ≥ 40 mm independently predicted overall mortality (hazard ratio [HR] 1.95; 95% confidence interval [CI], 1.01-3.83) and cardiac mortality (HR 3.09; 95% CI, 1.35-7.09) under conservative management. Mortality risk increased linearly with LVESD >40 mm (HR 1.15; 95% CI, 1.04-1.27 per 1-mm increment). Tribouilloy et al conclude that these findings support prompt surgical rescue in patients with LVESD ≥40 mm but also suggest that operating on patients before LVESD reaches 40 mm will best preserve survival.[8]
  • Magne et al found that exercise pulmonary hypertension can be predicted using resting comprehensive echocardiography in asymptomatic patients with degenerative MR.[9]
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Patient Education

For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education article Mitral Valve Prolapse.

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Contributor Information and Disclosures
Author

Ivan Hanson, MD  Fellow, Department of Cardiovascular Disease, William Beaumont Hospital

Ivan Hanson, MD, is a member of the following medical societies: American College of Cardiology and American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Luis C Afonso, MD  Assistant Professor, Department of Internal Medicine-Cardiology, Program Director of Cardiology Fellowship Program, Wayne State University; Director of Echocardiography Laboratory, Harper University Hospital

Luis C Afonso, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and American Society of Echocardiography

Disclosure: Nothing to disclose.

Specialty Editor Board

Martin Keane, MD, FACC, FAHA  Associate Professor, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania School of Medicine

Martin Keane, MD, FACC, FAHA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Heart Association, American Society of Echocardiography, Pennsylvania Medical Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ronald J Oudiz, MD, FACP, FACC, FCCP  Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, and American Thoracic Society

Disclosure: Actelion Grant/research funds Clinical Trials + honoraria; Encysive Grant/research funds Clinical Trials + honoraria; Gilead Grant/research funds Clinical Trials + honoraria; Pfizer Grant/research funds Clinical Trials + honoraria; United Therapeutics Grant/research funds Clinical Trials + honoraria; Lilly Grant/research funds Clinical Trials + honoraria; LungRx Clinical Trials + honoraria; Bayer Grant/research funds Consulting

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD  Professor and Executive Vice Chairman, Department of Medicine, Director, Office of Educational Programs, University of Texas Health Science Center at San Antonio

Richard A Lange, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, and Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Shivkumar H Jha, MD; Jatin Dave, MD, MPH; Kishorkumar Desai, MD; and Abraham G Kocheril, MD, FACC, FACP to the development and writing of this article.

References

  1. Bonow RO, Carabello BA, Kanu C, et al. 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): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. Aug 1 2006;114(5):e84-231. [Medline].

  2. [Best Evidence] Pizarro R, Bazzino OO, Oberti PF, Falconi M, Achilli F, Arias A, et al. Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J Am Coll Cardiol. Sep 15 2009;54(12):1099-106. [Medline].

  3. [Guideline] Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  4. Barbieri A, Bursi F, Grigioni F, Tribouilloy C, Avierinos JF, Michelena HI, et al. Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: A Multicenter Long-term International Study. Eur Heart J. Mar 2011;32(6):751-759. [Medline].

  5. Feldman T, Cilingiroglu M. Percutaneous leaflet repair and annuloplasty for mitral regurgitation. J Am Coll Cardiol. Feb 1 2011;57(5):529-37. [Medline].

  6. Feldman T, Foster E, Glower DG, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. Apr 14 2011;364(15):1395-406. [Medline].

  7. Rossi A, Dini FL, Faggiano P, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart. Oct 2011;97(20):1675-80. [Medline].

  8. [Best Evidence] Tribouilloy C, Grigioni F, Avierinos JF, Barbieri A, Rusinaru D, Szymanski C, et al. Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets a long-term follow-up multicenter study. J Am Coll Cardiol. Nov 17 2009;54(21):1961-8. [Medline].

  9. Magne J, Lancellotti P, O'Connor K, et al. Prediction of exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. J Am Soc Echocardiogr. Sep 2011;24(9):1004-12. [Medline].

  10. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol. Apr 19 2005;45(8):1334-40. [Medline].

  11. Carabello BA. Progress in mitral and aortic regurgitation. Prog Cardiovasc Dis. May-Jun 2001;43(6):457-75. [Medline].

  12. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. Mar 3 2005;352(9):875-83. [Medline].

  13. Fann JI, Ingels NB, Miller DC. Pathophysiology of Mitral Valve Disease. In: Cardiac Surgery in the Adult. 3rd ed. New York, NY: McGraw-Hill; 2008:chap 41.

  14. Khanna D, Miller AP, Nanda NC, et al. Transthoracic and transesophageal echocardiographic assessment of mitral regurgitation severity: usefulness of qualitative and semiquantitative techniques. Echocardiography. Oct 2005;22(9):748-69. [Medline].

  15. Libby P, Bonow RO, MD, Zipes DP, Mann DL. Valvular Heart Disease. In: Braunwald's Heart Disease. 8th ed. Philadelphia, PA: Saunders Elsevier; 2008:chap. 62.

  16. Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation. Aug 30 2005;112(9 Suppl):I453-7. [Medline].

  17. Mehta RH, Eagle KA, Coombs LP, Peterson ED, Edwards FH, Pagani FD, et al. Influence of age on outcomes in patients undergoing mitral valve replacement. Ann Thorac Surg. Nov 2002;74(5):1459-67. [Medline].

  18. Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. May 9 2006;113(18):2238-44. [Medline].

  19. Thourani VH, Weintraub WS, Guyton RA, Jones EL, Williams WH, Elkabbani S, et al. Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting. Circulation. Jul 22 2003;108(3):298-304. [Medline].

 
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Transthoracic echocardiogram demonstrating severe mitral regurgitation with heavily calcified mitral valve and prolapse of the posterior leaflet into the left atrium.
Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.
 
 
 
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