Mitral Regurgitation Treatment & Management

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.^[3] 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.

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.

• 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.^[4]

ACC/AHA indications^[1] for mitral valve surgery

• 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

  • Symptomatic
    • 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
    • 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).

Percutaneous treatment of mitral regurgitation

• Various percutaneous strategies for treatment of MR are currently under investigation.^[5]
• 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.^[6]

  • 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.
  • 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.
  • At 12 months, 19% of the percutaneous repair group had residual 3+ 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.
• 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.

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

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

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