eMedicine Specialties > Cardiology > Valvular Heart Disease
Mitral Regurgitation: Treatment & Medication
Updated: Oct 29, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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 have recently changed.12 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.
Surgical Care
- 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.
- 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.
- ACC/AHA indications1 for mitral valve surgery
- Repair of mitral valve is recommended over replacement in most of patients with severe 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
- Symptomatic
- New York Heart Association (NYHA) functional class II-IV symptoms without severe LV dysfunction (EF ³ 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
- Asymptomatic patients with chronic, severe MR and mild-to-moderate LV dysfunction (EF 0.65 and/or end-systolic dimension ³ 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).
- Symptomatic
Consultations
Consult specialists in cardiology and cardiothoracic surgery early during the patient evaluation in the emergency department.
Diet
A diet low in sodium is indicated for patients with symptomatic chronic MR or those with LV dysfunction.
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
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Diuretics
Help decrease pulmonary congestion.
Furosemide (Lasix)
Increases excretion of water by interfering with chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule. Dose must be individualized to patient.
Adult
20-80 mg/d PO as single dose; second dose can be administered 6-8 h later depending on response; increments of 20-40 mg can be given, but no sooner than within 6-8 h of the previous dose until desired diuresis achieved; if dose is >80 mg/d, can be given qd or bid; perform clinical and laboratory tests
Alternatively, administer 20-40 mg IM/IV; IV injection should be given slowly (over 1-2 min); if response not satisfactory within 1 h, dose can be increased to 80 mg IV (over 1-2 min)
Pediatric
2 mg/kg PO; increase by 1-2 mg/kg no sooner than 6-8 h after previous dose; doses > 6 mg/kg not recommended
Alternatively, 1 mg/kg IV/IM can be given slowly under close supervision; in case of unsatisfactory response, dose can be increased by 1 mg/kg no sooner than 2 h after previous dose until desired effects are seen; doses > 6 mg/kg not recommended
Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; auditory toxicity appears to be increased with coadministration of aminoglycosides; hearing loss of varying degrees may occur; anticoagulant activity of warfarin may be enhanced when taken concurrently; increased plasma lithium levels and toxicity are possible when taken concurrently
Documented hypersensitivity to product or sulfonylureas; hepatic coma; anuria; state of severe electrolyte depletion until condition is improved or corrected
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Perform frequent serum electrolyte, carbon dioxide, glucose, creatinine, uric acid, calcium, and BUN determinations during first few months of therapy and periodically thereafter
Angiotensin-converting enzyme inhibitors
Used in the presence of MR for afterload reduction.
Captopril (Capoten)
Competitive inhibitor of ACE. Reduces angiotensin II levels, decreasing aldosterone secretion. Goal is to decrease afterload to left ventricle (by reducing systemic blood pressure and by peripheral vasodilatation), which decreases amount of blood pumped by left ventricle and pressure at which blood is being ejected. This reduces amount of blood regurgitated by mitral valve from the left ventricle into the left atrium during systole. Elimination of drug is primarily by renal excretion. Impaired renal function requires dosage reduction. Absorbed well PO. Give at least 1 h before meals. If added to water, use within 15 min.
Adult
25 mg PO tid 1 h pc; most patients improve with 50-100 mg PO tid; allow up to 2 wk to determine satisfactory response; not to exceed 450 mg/d
Pediatric
Neonates: 0.1-0.4 mg/kg/d, PO divided q6-8h
Infants (<2 mo): 0.05-0.1 mg/kg/dose, PO q6h or q8h
Children: 0.15 mg/kg/dose PO q8h initially
NSAIDs may reduce hypotensive effects; ACE inhibitors may increase digoxin, lithium, and allopurinol levels; rifampin decreases levels; probenecid may increase levels; hypotensive effects of ACE inhibitors may be enhanced when given concurrently with diuretics
Documented hypersensitivity; renal impairment; patients who have experienced angioedema during therapy with other ACE inhibitors
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal impairment, valvular stenosis, or severe congestive heart failure; adjust dose in patients with acute renal failure; pruritic rash, photosensitivity, proteinuria (1:100 patients), neutropenia/agranulocytosis, anemia, thrombocytopenia, pancytopenia, cough (0.5-2% of patients), bronchospasm, hypotension, diminution of taste perception (ie, dysgeusia), angioedema, asthenia, gynecomastia, blurred vision, and impotence have been reported
Enalapril (Vasotec)
Competitive inhibitor of ACE. Reduces angiotensin II levels, decreasing aldosterone secretion. Goal is to decrease afterload to left ventricle (by reducing systemic blood pressure and by peripheral vasodilatation), which decreases amount of blood being pumped by left ventricle and pressure at which blood is being ejected. This reduces amount of blood regurgitated by the mitral valve from left ventricle into left atrium during systole.
Adult
2.5 mg PO bid initially; therapeutic range approximately 2.5-20 mg/d in 2 divided doses; not to exceed 40 mg/d
Pediatric
0.1 mg/kg PO bid/qid, not to exceed 40 mg/d
5-10 mcg/kg (micro) slow IV over 5 min qid, not to exceed 1.25 mg
NSAIDs may reduce hypotensive effects; ACE inhibitors may increase digoxin, lithium, and allopurinol levels; rifampin decreases levels; probenecid may increase levels; hypotensive effects of ACE inhibitors may be enhanced when given concurrently with diuretics; potassium-sparing agents potentiate hyperkalemic effects
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal impairment, valvular stenosis, or severe congestive heart failure; reduce dose in renal failure
Lisinopril (Zestril, Prinivil)
Prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion.
Adult
5 mg/d PO with diuretics and digitalis; usual effective dosage range is 5-20 mg qd; in hyponatremic patients (s-sodium <130 mEq/L), initiate dose at 2.5 mg qd
Pediatric
Not established
NSAIDs may reduce hypotensive effects; ACE inhibitors may increase digoxin, lithium, and allopurinol levels; rifampin decreases levels; probenecid may increase levels; hypotensive effects of ACE inhibitors may be enhanced when given concurrently with diuretics
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with renal impairment, valvular stenosis, or severe congestive heart failure
Nitrates
Used for decreasing blood pressure and increasing coronary blood flow.
Nitroglycerin (Deponit, Nitro-Bid, Nitrostat, Nitrol)
Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate production. Result is decrease in blood pressure.
Adult
SL: Dissolve 1 tab under tongue or in buccal pouch at first sign of acute anginal attack; repeat q5min until relief obtained; do not use > 3 tab in 15 min; can also be used prophylactically 5-10 min prior to activities that may precipitate angina
SR tab: 2.5-2.6 mg tid/qid with possible increase in increments of 2.5-2.6 mg bid/qid depending on response; caps must be swallowed and are not for chewing or SL use
Transdermal patch: Apply qd to skin site free of hair and not subject to excessive movement; 0.2-0.4 mg/h initially; patch-on period of 12-14 h and patch-off period of 10-12 h is appropriate; doses 0.4-0.8 mg/h have shown continued effectiveness for 10-12 h qd for at least 1 mo of intermittent administration; nitrate-free interval of 10-12 h is sufficient; tolerance is major factor in limiting efficacy when system is used continuously for >12 h
Topical: Usual therapeutic dose is 1-2 in q8h, not to exceed 4-5 in q4h; begin with 0.5 in q8h and increase by 0.5 in with each application to achieve desired effects; 1 in of ointment contains 15 mg of nitroglycerin
Pediatric
Not established
Aspirin may increase serum concentrations; marked symptomatic orthostatic hypotension may occur with coadministration of calcium channel blockers (dose adjustment of either agent may be necessary)
Documented hypersensitivity; severe anemia; shock; postural hypotension; head trauma; closed-angle glaucoma; cerebral hemorrhage
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in coronary artery disease and low systolic blood pressure
Inotropic agents
Because of its antiarrhythmic properties, digoxin is used if atrial fibrillation is encountered; however, it is not expected to improve overall cardiac function.
Digoxin (Lanoxin)
Cardiac glycoside with direct inotropic effects in addition to indirect effects on cardiovascular system. Acts directly on cardiac muscle, increasing myocardial systolic contractions. Indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.
Digitalizing dose is approximately 20% less than PO dose. IM injection offers no advantage and can cause severe pain at injection site. IV is preferred. IV digoxin begins to have effect after 15-30 min and peaks in 1.5-3 h.
Adult
0.5 mg slow IV over 10-20 min; additional 0.25 or 0.125 mg may be administered after 3 h; total dose of 1-1.25 mg is usually required to achieve full digitalis effect, but smaller doses might be adequate in older patients and those with small, lean body mass
If a full effect is desired rapidly, administer 1-1.25 mg in divided doses over initial 24-h period; an additional 0.5 mg is added during the second 24-h period; 0.5 mg PO qd for 3 d can achieve maximal effects, which can follow usual maintenance dose; PO maintenance dose ranges from 0.125-0.5 mg qd; smaller doses are necessary in presence of renal insufficiency
Pediatric
Loading dose: 10 mcg/kg PO; not to exceed 375 mcg
Maintenance dose: 5 mcg/kg PO, not to exceed 125 mcg
Premature infants: Half loading and maintenance dose q6h X 4
If given IV, administer 75% of PO dose bid
IV calcium may produce arrhythmias in digitalized patients
Medications that may increase levels include alprazolam, benzodiazepines, bepridil, captopril, cyclosporine, propafenone, propantheline, quinidine, diltiazem, aminoglycosides, oral amiodarone, anticholinergics, diphenoxylate, erythromycin, felodipine, flecainide, hydroxychloroquine, itraconazole, nifedipine, omeprazole, quinine, ibuprofen, indomethacin, esmolol, tetracycline, tolbutamide, and verapamil
Medications that may decrease serum levels include aminoglutethimide, antihistamines, cholestyramine, neomycin, penicillamine, aminoglycosides, oral colestipol, hydantoins, hypoglycemic agents, antineoplastic treatment combinations (including carmustine, bleomycin, methotrexate, cytarabine, doxorubicin, cyclophosphamide, vincristine, procarbazine), aluminum or magnesium antacids, rifampin, sucralfate, sulfasalazine, barbiturates, kaolin/pectin, and aminosalicylic acid
Documented hypersensitivity; beriberi heart disease; idiopathic hypertrophic subaortic stenosis; constrictive pericarditis; carotid sinus syndrome
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hypokalemia may reduce positive inotropic effect; hypercalcemia predisposes patients to digitalis toxicity, and hypocalcemia can make digoxin ineffective until serum calcium levels are within reference range; magnesium replacement therapy must be instituted in patients with hypomagnesemia to prevent digitalis toxicity; patients diagnosed with incomplete AV block may progress to complete block when treated with digoxin; exercise caution in patients with hypothyroidism, hypoxia, and acute myocarditis; adjust dose in patients with renal impairment; highly toxic (overdoses can be fatal)
Antibiotics, prophylactic
Provide subacute bacterial endocarditis prophylaxis. Use prior to any interventional therapy to protect the diseased valves.
Cephalexin (Keflex)
First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococcal or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected.
Used orally when outpatient management is indicated.
Adult
2 g PO 1h before procedure
Pediatric
50 mg/kg PO 1h before procedure; not to exceed 2 g/dose
Coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of non-susceptible organisms may occur with prolonged use or repeated therapy
Ampicillin (Marcillin, Omnipen)
For prophylaxis in patients undergoing dental, oral, or respiratory tract procedures. Coadministered with gentamicin for prophylaxis in GI or GU procedures.
Adult
2 g IV/IM 30 min before procedure
High-risk patients: 2 g ampicillin IV/IM plus 1.5 mg/kg gentamicin 30 min before procedure
Pediatric
<30 kg: 50 mg/kg IV/IM 30 min before procedure
High-risk patients: 50 mg/kg IV/IM ampicillin plus 1.5 mg/kg gentamicin 30 min before procedure
>30 kg: Administer as in adults
Probenecid and disulfiram elevate levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Adjust dose in patients with renal failure; evaluate rash and differentiate from hypersensitivity reaction
Amoxicillin (Amoxil, Trimox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. Used as prophylaxis in minor procedures.
Adult
2 g PO 1 h before procedure
Pediatric
<30 kg: 50 mg/kg 1 h before procedure
>30 kg: Administer as in adults
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in patients with renal impairment
Clindamycin (Cleocin)
Used in patients who are allergic to penicillin and are undergoing dental, oral, or respiratory tract procedures. Useful for treatment against streptococcal and most staphylococcal infections.
Adult
600 mg PO/IV 1 h before procedure
Pediatric
<30 kg: 10 mg/kg PO 1 h before procedure; not to exceed 600 mg
>30 kg: Administer as in adults
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in patients with severe hepatic dysfunction; no adjustment necessary in patients with renal insufficiency; associated with severe and possibly fatal colitis
Gentamicin (Garamycin)
Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in GI and GU procedures.
Adult
1.5 mg/kg IV with ampicillin (1-2 g) 30 min before procedure; not to exceed 80 mg
Pediatric
<30 kg: 2 mg/kg IV with ampicillin (50 mg/kg) 30 min before procedure
>30 kg: Administer as in adults
Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Narrow therapeutic index (not intended for long-term therapy); caution in patients with renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in patients with renal impairment
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive, or have not responded to, penicillins and cephalosporins or who have infections with resistant staphylococci.
Use CrCl to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in patients who are allergic to penicillin and are undergoing GI or GU procedures.
Adult
Dental, oral, or upper respiratory tract surgery: 1 g IV, infused over 1 h, 1 h before procedure
GI/GU procedures: 1 g plus 1.5 mg/kg gentamicin infused over 1 h, 1 h prior to surgery
Pediatric
Dental, oral, or upper respiratory tract surgery
<30 kg: 20 mg/kg 1 h before procedure
>30 kg: Administer as in adults
Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients with renal failure or neutropenia; red man syndrome is caused by IV infusion that is too rapid (dose given over a few min) but rarely happens when dose given as 2-h administration or as PO/IP administration; red man syndrome is not an allergic reaction
Erythromycin (EES, E-Mycin, Eryc)
Used for prophylaxis in patients who are allergic to penicillin and are undergoing dental, oral, or respiratory tract procedures.
Adult
1 g PO 1-2 h before procedure
Pediatric
<30 kg: 20 mg/kg PO 2 h before procedure
>30 kg: Administer as in adults
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in patients with liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Azithromycin (Zithromax)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
500 mg PO 1 h before procedure
Pediatric
<30 kg: 15 mg/kg PO 1 h before procedure
>30 kg: Administer as in adults
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in patients who are hospitalized, geriatric, or debilitated
Clarithromycin (Biaxin)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
500 mg PO 1 h before procedure
Pediatric
15 mg/kg PO 1 h before procedure; not to exceed 500 mg/dose
Toxicity increases with coadministration of fluconazole and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, carbamazepine, ergot alkaloids, triazolam, and HMG-CoA reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increases in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Documented hypersensitivity; coadministration of pimozide
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies
Cefazolin (Ancef)
First-generation semisynthetic cephalosporins that arrest bacterial cell wall synthesis, inhibiting bacterial growth. Primarily active against skin flora, including Staphylococcus aureus.
Adult
1 g IV/IM within 30 min before procedure
Pediatric
<30 kg: 25 mg/kg IV/IM within 30 min before procedure
>30 kg: Administer as in adults
Coadministration with furosemide or aminoglycosides may increase nephrotoxicity; probenecid prolongs effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in patients with renal impairment; superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Cefadroxil (Duricef)
First generation semi-synthetic cephalosporin, that arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primarily active against skin flora, including Staphylococcus aureus.
Adult
2 g PO 1 h before procedure
Pediatric
50 mg/kg PO 1 h before procedure
>30 kg: Administer as in adults
Probenecid may decrease clearance of cephalosporins; aminoglycosides and furosemide may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); prolonged use may result in superinfection
More on Mitral Regurgitation |
| Overview: Mitral Regurgitation |
| Differential Diagnoses & Workup: Mitral Regurgitation |
 Treatment & Medication: Mitral Regurgitation |
| Follow-up: Mitral Regurgitation |
| Multimedia: Mitral Regurgitation |
| References |
| « Previous Page | Next Page » |
References
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Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation. Aug 30 2005;112(9 Suppl):I453-7. [Medline].
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].
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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].
[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].
[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].
Further Reading
Keywords
mitral regurgitation, MR, mitral incompetence, mitral insufficiency, myxomatous degeneration, ruptured chordae tendineae, collagen-vascular disease, collagen vascular disease, rheumatic fever, myxomatous mitral valve, Down syndrome, Down's syndrome, acute mitral valve regurgitation, mitral valve regurgitation, mitral valve incompetence, mitral valve insufficiency, cardiogenic shock, mitral valve disease, mitral valvular abnormality, prosthetic valve failure, perforated mitral valve leaflet, perforated mitral valve, mitral valve prolapse, MVP, rheumatic heart disease, coronary artery disease, CAD, annular calcification, connective tissue disorder, connective-tissue disorder, left ventricle dilation, left ventricle dilatation, LV dilation, LV dilatation, prosthetic heart valve, cardiac valvular lesion, functional ischemic mitral regurgitation
