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Mitral Regurgitation Workup

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

Imaging Studies

Chest radiography

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.

Echocardiography

European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) criteria for the definition of severe MR are as follows[1] :

  • 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.[4]

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
  • Regurgitation volume
  • 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.

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

ACC/AHA Class I indications for performing serial transthoracic echocardiography include the following[4] :

  • 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[4] :

  • 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
    Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
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Other Tests

Electrocardiography

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.

BNP assessment

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.[5]

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Procedures

ACC/AHA Class I indications for performing cardiac catheterization are as follows[4] :

  • 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.
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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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