Mitral Regurgitation Workup
- Author: Ivan Hanson, MD; Chief Editor: Richard A Lange, MD, MBA more...
Evidence of LV enlargement due to volume overload may be observed (particularly in chronic MR), although pulmonary congestion (eg, increased pulmonary markings) may not be observed until heart failure has developed.
Left atrial enlargement may also be observed in the AP view as a double shadow in the right cardiac silhouette and/or straightening of the left cardiac border due to the large left atrial appendage.
European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) criteria for the definition of severe MR are as follows :
Flail leaflet/ruptured papillary muscle/large coaptation defect
Very large color flow central jet or eccentric jet adhering, swirling, and reaching the posterior wall of the left atrium
Dense/triangular continuous-wave signal of regurgitant jet
Large flow convergence zone
ACC/AHA Class I indications for performing transthoracic echocardiography include (1) baseline evaluation for LV size and function, RV and LA size, pulmonary artery pressure, and severity of MR; (2) determining the etiology of MR; (3) annual or semiannual surveillance of LV ejection fraction and end-systolic dimension in asymptomatic patients with moderate-to-severe MR; (4) evaluation of the mitral valve apparatus and LV function after a change in signs or symptoms; and (5) evaluation of LV size and function and mitral valve hemodynamics in the initial evaluation after MV replacement or repair.
Parameters of severity of MR include the following:
Color flow jet width and area
Intensity of continuous-wave Doppler signal
Pulmonary venous flow contour
Peak early mitral inflow velocity
Regurgitant orifice area
Left ventricular and left atrial size
In evaluating the etiology of MR, note that with acute MR, a ruptured chordae tendineae or papillary muscle, a flail valve leaflet, or infective endocarditis may be identified as the etiology. A central color flow jet of MR with a structurally normal mitral valve suggests functional MR.
ACC/AHA Class I indications for performing serial transthoracic echocardiography include the following :
Asymptomatic patients with mild MR and no evidence of LV enlargement, LV dysfunction, or pulmonary hypertension can be observed on a yearly basis; serial echocardiography is not indicated.
Patients with moderate MR should have an echocardiogram performed yearly.
In asymptomatic patients with severe MR, echocardiography and clinical evaluation should be done every 6-12 months to assess symptoms and development of LV dysfunction.
ACC/AHA Class I indications for performing transesophageal echocardiography are as follows :
Assessment of etiology of severe MR in patients for whom surgery is recommended to determine the feasibility of valve repair
Evaluation of mitral valve and associated structures in patients for whom transthoracic echocardiography provides nondiagnostic information
Findings on electrocardiography may include the following:
Ischemia or infarction in the inferior or posterior leads is present when acute MR is due to papillary muscle rupture.
In chronic mitral valve regurgitation, LV dilatation and hypertrophy are observed with increased QRS voltage and ST-T wave changes in the lateral precordial leads.
Left atrial enlargement in chronic mitral valve regurgitation produces a negative P wave in lead V 1, and/or a wide notched P wave in leads II, III, or aVF. Atrial fibrillation may be observed in the late stages.
Pizarro et al found that in patients with severe asymptomatic mitral regurgitation and normal left ventricular function, levels of brain natriuretic peptide (BNP) have an independent and additive prognostic value. In a prospective study of 269 consecutive patients with severe asymptomatic organic mitral regurgitation and left ventricular ejection fraction above 60%, the receiver-operating characteristics curve yielded an optimal cutoff point of 105 pg/mL of BNP that was able to discriminate patients at higher risk. Pizarro et al recommend considering BNP assessment in the routine clinical workup for risk stratification, which may aid in the selection of patients for early surgery.
ACC/AHA Class I indications for performing cardiac catheterization are as follows :
Left ventriculography and hemodynamic measurements are indicated when noninvasive tests are inconclusive regarding severity of MR, LV function, or the need for surgery.
Hemodynamic measurements are indicated when pulmonary artery pressure is out of proportion to the severity of MR as assessed by noninvasive testing.
Left ventriculography and hemodynamic measurements are indicated when the clinical and noninvasive findings are conflicting regarding severity of MR.
Coronary angiography is indicated before MV repair or MV replacement in patients at risk for coronary artery disease or when the MR is suspected to be ischemic in origin.
[Guideline] Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012 Oct. 33(19):2451-96. [Medline].
O'Riordan M. FDA approves MitraClip for degenerative MR. October 25, 2013. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/813216. Accessed: October 28, 2013.
Abbott. Abbott's first-in-class MitraClip device now available for U.S. patients [press release]. October 25, 2013. Available at http://www.abbott.com/press-release/abbotts-firstinclass-mitraclip-device-now-available-for-us-patients.htm. Accessed: October 28, 2013.
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. 2006 Aug 1. 114(5):e84-231. [Medline].
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. 2009 Sep 15. 54(12):1099-106. [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. 2007 Oct 9. 116(15):1736-54. [Medline].
O’Riordan M. Early surgery bests "watchful waiting" in severe MR patients without symptoms. Medscape Medical News. Accessed August 19, 2013. Available at http://www.medscape.com/viewarticle/809403.
Suri RM, Vanoverschelde JL, Grigioni F, Schaff HV, Tribouilloy C, Avierinos JF, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA. 2013 Aug 14. 310(6):609-16. [Medline].
Otto CM. Surgery for mitral regurgitation: sooner or later?. JAMA. 2013 Aug 14. 310(6):587-8. [Medline].
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. 2011 Mar. 32(6):751-759. [Medline].
Fino C, Iacovoni A, Ferrero P, et al. Determinants of functional capacity after mitral valve annuloplasty or replacement for ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2015 Jun. 149 (6):1595-603. [Medline].
Feldman T, Cilingiroglu M. Percutaneous leaflet repair and annuloplasty for mitral regurgitation. J Am Coll Cardiol. 2011 Feb 1. 57(5):529-37. [Medline].
Feldman T, Foster E, Glower DG, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011 Apr 14. 364(15):1395-406. [Medline].
Castleberry AW, Williams JB, Daneshmand MA, et al. Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience. Circulation. 2014 Jun 17. 129 (24):2547-56. [Medline].
Feldman T, Kar S, Elmariah S, Smart SC, et al, for the EVEREST II Investigators. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-Year results of EVEREST II. J Am Coll Cardiol. 2015 Dec 29. 66 (25):2844-54. [Medline].
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. 2011 Oct. 97(20):1675-80. [Medline].
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. 2009 Nov 17. 54(21):1961-8. [Medline].
Magne J, Lancellotti P, O'Connor K, et al. Prediction of exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. J Am Soc Echocardiogr. 2011 Sep. 24(9):1004-12. [Medline].
Acker MA, Parides MK, Perrault LP, et al, for The Cardiothoracic Surgical Trials Network. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2013 Nov 18. [Medline]. [Full Text].
Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol. 2005 Apr 19. 45(8):1334-40. [Medline].
Carabello BA. Progress in mitral and aortic regurgitation. Prog Cardiovasc Dis. 2001 May-Jun. 43(6):457-75. [Medline].
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. 2005 Mar 3. 352(9):875-83. [Medline].
Fann JI, Ingels NB, Miller DC. Pathophysiology of Mitral Valve Disease. Cardiac Surgery in the Adult. 3rd ed. New York, NY: McGraw-Hill; 2008. chap 41.
Khanna D, Miller AP, Nanda NC, et al. Transthoracic and transesophageal echocardiographic assessment of mitral regurgitation severity: usefulness of qualitative and semiquantitative techniques. Echocardiography. 2005 Oct. 22(9):748-69. [Medline].
Libby P, Bonow RO, MD, Zipes DP, Mann DL. Valvular Heart Disease. Braunwald's Heart Disease. 8th ed. Philadelphia, PA: Saunders Elsevier; 2008. chap. 62.
Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation. 2005 Aug 30. 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. 2002 Nov. 74(5):1459-67. [Medline].
O'Riordan M. Repair and surgery fare equally well in ischemic MR. Heartwire. November 18, 2013. [Full Text].
Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. 2006 May 9. 113(18):2238-44. [Medline].
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. 2003 Jul 22. 108(3):298-304. [Medline].
Vahanian A, Iung B. Mitral regurgitation: Timing of surgery or interventional treatment. Herz. 2015 Dec 10. [Medline].