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Mitral Regurgitation Treatment & Management

  • Author: Ivan Hanson, MD; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: Jan 03, 2016
 

Medical Care

Prehospital care

For the patient with acute MR, the electrocardiogram should be examined closely for evidence of acute myocardial infarction (MI). If present, treatment with supplemental oxygen, analgesics for anginal chest pain, and sublingual nitrates for acute MI are the components of prehospital care. In the absence of acute MI, endocarditis should be excluded with blood cultures.

Transthoracic echocardiography should be performed.

Emergency department care

Any patient with acute or chronic mitral valve regurgitation with hemodynamic compromise should be evaluated for acute myocardial infarction. Consultations with specialists in cardiology and cardiothoracic surgery should be obtained early during patient stabilization.

Diuretic therapy is administered to individuals with pulmonary congestion, and an echocardiogram must be performed immediately. Patients with hemodynamic compromise should be expeditiously transferred to a cardiac critical care unit for central and pulmonary arterial pressure monitoring.

Medical therapy

Afterload-reducing agents (such as nitrates and antihypertensive drugs) and diuretics are helpful for maintaining the forward cardiac output in persons with MR with symptoms and/or LV dysfunction. Beta-blockers and biventricular pacing are used for primary treatment of LV dysfunction in functional MR.

Intra-aortic balloon counterpulsation should be considered in the patient with acute MR and hemodynamic compromise.

If atrial fibrillation is encountered, maintenance of a normal ventricular response with beta-blockers, calcium channel blockers, and/or digitalis therapy is considered.

Anticoagulation is considered for patients who develop atrial fibrillation or have had mitral valve replacement surgery.

Guidelines for the use of prophylactic antibiotics prior to periodontal procedures continue to evolve.[6] In addition to maintaining good oral hygiene, antibiotics are recommended prior to any dental procedure that involves manipulation of gingival tissue, the periapical region of a tooth, or perforation of oral mucosa in patients with any of the following conditions:

  • Prosthetic heart valve
  • Previous infectious endocarditis
  • Some forms of congenital heart disease
  • Valvulopathy in a cardiac transplant recipient

Inotropic agents should be considered in chronic severely symptomatic MR, and consultation with a specialist in cardiothoracic surgery should be obtained.

ESC/EACTS guidelines recommend reducing filling pressures in acute MR with nitrates and diuretics. Afterload and regurgitant fraction can be reduced with nitroprusside or an intra-aortic balloon pump. In patients with hypotension, inotropic agents and an intra-aortic balloon pump should be used. In patients with advanced MR and severe symptoms in whom heart failure has developed and who are not suitable for surgery or who have residual symptoms following surgery, ACE inhibitors, beta-blockers and spironolactone should be considered.[1]

A study using data from the Mitral Regurgitation International Database (MIDA) found that patients with severe MR without a class I indication for surgical intervention fared significantly better when they were treated with surgery than when they underwent “watchful waiting” while being treated with medical therapy. The survival differences were statistically significant, and the results were confirmed in propensity score-matched and inverse-probability–weighted analyses.[7, 8, 9]

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Surgical Care

Invasive management

The risks and benefits of surgery should be assessed based on the age and comorbidity of each individual patient, with the decision to proceed or not to proceed being grounded in uniformly accepted guidelines. Consider the following:

  • Operative mortality is higher in the patients older than 75 years.
  • Coronary artery disease and other valvular diseases are prevalent in older patients who often require concomitant coronary artery bypass surgery, further increasing operative risk.
  • As outcomes are worse in patients with severe MR and pulmonary hypertension (pulmonary artery systolic pressure >50 mm Hg), surgical referral is advised prior to development of pulmonary hypertension. [10]

In a retrospective study of 121 patients with significant chronic ischemic mitral regurgitation, intervention with mitral valve replacement  was associated with improved postoperative exercise hemodynamic performance and long-term functional capacity compared with mitral valve annuloplasty.[11]

ACC/AHA indications for mitral valve surgery [4]

Repair of mitral valve is recommended over replacement in most patients with moderate-to-severe (3+) or severe (4+) chronic MR who require surgery, and patients should be referred to experienced surgical centers (Class I).

Surgery is indicated for symptomatic patients with acute severe MR (Class I).

Chronic severe MR is classified as symptomatic or asysmptomatic. Symptomatic chronic severe MR includes the following features:

  • New York Heart Association (NYHA) functional Class II-IV symptoms without severe LV dysfunction (EF ≥0.30 and/or end-systolic dimension ≤55 mm) (Class I).
  • Chronic severe MR due to a primary abnormality of the mitral valve apparatus and NYHA functional Class III-IV symptoms and mild-to-moderate LV dysfunction (EF < 0.30 and/or end-systolic dimension >55 mm) in whom MV repair is highly likely (Class IIa).

Asymptomatic chronic severe MR includes the following features:

  • Asymptomatic patients with chronic, severe MR and mild-to-moderate LV dysfunction (EF 0.65 and/or end-systolic dimension ≥45 mm) (Class I).
  • Mitral valve repair is reasonable in experienced centers for asymptomatic patients with chronic severe MR with preserved LV function (EF >0.65 and end-systolic dimension < 45 mm) in whom the likelihood of successful repair without residual MR is greater than 90% (Class IIa).
  • Surgery is reasonable for asymptomatic patients with chronic severe MR, preserved LV function, new onset atrial fibrillation, or pulmonary artery hypertension (pulmonary artery systolic pressure >50 mm Hg at rest or >60 mm Hg with exercise) (Class IIa).

ESC/EACTS indications for mitral valve surgery in severe primary MR [1]

Mitral valve repair should be the preferred technique when it is expected to be durable (Class I).

Surgery is indicated in the following situations:

  • Asymptomatic patients with LVEF >30% and end-systolic dimension < 55 mm (Class I).
  • Asymptomatic patients with LV end-systolic dimension ≥45 mm and/or LVEF ≤60% (Class I)

Surgery should be considered in the following situations:

  • Asymptomatic patients with preserved LV function and new onset atrial fibrillation or pulmonary hypertension (Class IIa)
  • Asymptomatic patients with preserved LV function and a high likelihood of durable repair, low surgical risk and flail leaflet, and LV end-systolic dimension ≥40 mm (Class IIa)
  • Patients with severe LV dysfunction refractory to medical therapy with a high likelihood of durable repair and low comorbidity (Class IIa)

Surgery may be considered in the following situations:

  • Patients with severe LV dysfunction refractory to medical therapy with low likelihood of durable repair and low comorbidity (Class IIb)
  • Asymptomatic patients with preserved LV function, high likelihood of durable repair, low surgical risk, and either left atrial dilatation and sinus rhythym or pulmonary hypertension on exercise

Percutaneous treatment of mitral regurgitation

In October 2013, the FDA approved the MitraClip valve repair system for patients with symptomatic degenerative MR with a prohibitive risk for mitral-valve surgery.[2, 3] Approval was based on registry data and the Endovascular Valve Edge-to-Edge Repair Study (EVEREST II), in which percutaneous repair of the mitral valve was less effective in reducing MR but was associated with similar improvement in clinical outcomes and with superior safety.[2, 3]

Various percutaneous strategies for treatment of MR are also under investigation.[12]

Double-orifice mitral valve repair using an implanted device that grasps and approximates the edges of the mitral valve leaflets at the origin of the regurgitant jet has been compared with mitral valve surgery for patients with 3+ to 4+ MR in a randomized trial.[13] At 12 months, the primary combined endpoint of survival, surgery for mitral valve dysfunction, and grade 3+ to 4+ MR was met in 55% of patients randomized to percutaneous repair and 73% of patients in the surgical group (p = 0.007). Major adverse events at 30 days occurred in 27% of patients who underwent percutaneous repair and 45% of patients who underwent surgery (p < 0.001). When transfusions were excluded from the safety analysis, no statistically significant difference in major adverse events was found between the groups.[13]

At 12 months, 20% of the percutaneous repair group required surgery for mitral valve dysfunction (p< 0.001) compared with 2.2% of the surgery group.[13] At 12 months, 19% of the percutaneous repair group had residual3+ or 4+ MR compared with 6% of the surgery group. Patients in the surgical group had greater improvement in ejection fraction than those in the percutaneous repair group (p = 0.005). Physical quality of life at 30 days was worse in the surgical group (p < 0.001); however, at 12 months, no significant difference was found.[13]

Percutaneous double-orifice mitral valve repair appears safer than surgery, primarily due to reduced risk of transfusion. Although surgery results in more favorable reduction of MR, quality of life at one year is similar for both approaches. Surgical mitral valve repair remains the criterion standard intervention for severe MR; however, percutaneous double-orifice repair is a viable alternative for patients at high risk for surgery.

In a retrospective study (1990-2009) of data from 4989 patients with significant coronary artery disease who were treated for moderate or severe ischemic mitral regurgitation, intervention with coronary artery bypass grafting (CABG) alone was associated with the lowest mortality.[14] CABG with or without mitral valve surgery was associated with a lower mortality than for either percutaneous coronary intervention or medical treatment alone.[14]

The 5-year results from the EVEREST II (Endovascular Valve Edge-to-Edge Repair Study) that compared percutaneous mitral valve repair with the MitraClip device with conventional mitral valve surgery revealed increased rates of grade 3+ and 4+ mitral regurgitation (12.3%) and surgery (27.9%) with percutaneous repair than with conventional repair (1.8% and 8.9%, respectively).[15] The majority of surgery following percutaneous repair (78%) occured within the first 6 months. The 5-year mortality was similar between the two groups: 20.8% for percutaneous repair and 26.8% for conventional surgery.[15]

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Consultations

Consult specialists in cardiology and cardiothoracic surgery early during the patient evaluation in the emergency department.

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Diet

A diet low in sodium is indicated for patients with symptomatic chronic MR or those with LV dysfunction.

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Activity

Asymptomatic patients with MR of any severity can exercise without restriction if all of the following criteria are met:

  • Sinus rhythm
  • Normal LV and left atrial dimensions
  • Normal pulmonary artery pressure
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Contributor Information and Disclosures
Author

Ivan Hanson, MD Assistant Professor of Medicine, Oakland University William Beaumont School of Medicine

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

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, American Society of Echocardiography

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Thoracic Society, American College of Physicians, American Heart Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Actelion, Bayer, Gilead, Lung Biotechnology, United Therapeutics<br/>Received research grant from: Actelion, Bayer, Gilead, Ikaria, Lung Biotechnology, Pfizer, Reata, United Therapeutics<br/>Received income in an amount equal to or greater than $250 from: Actelion, Bayer, Gilead, Lung Biotechnology, Medtronic, Reata, United Therapeutics.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

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

Disclosure: Nothing to disclose.

Additional Contributors

Martin Gerard Keane, MD, FACC, FAHA Professor, Cardiovascular Medicine, Department of Medicine, Temple University School of Medicine

Martin Gerard 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference 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
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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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