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
ACC/AHA Class I indications[1] for performing transthoracic echocardiography
- Baseline evaluation for LV size and function, RV and LA size, pulmonary artery pressure, and severity of MR
- Parameters of severity of MR
- 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
- Parameters of severity of MR
- Determining the etiology of MR
- 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.
- Annual or semiannual surveillance of LV ejection fraction and end-systolic dimension in asymptomatic patients with moderate-to-severe MR
- Evaluation of the mitral valve apparatus and LV function after a change in signs or symptoms
- Evaluation of LV size and function and mitral valve hemodynamics in the initial evaluation after MV replacement or repair.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[1] for performing serial transthoracic echocardiography
- 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[1] for performing transesophageal echocardiography
- 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.
Other Tests
Electrocardiography
- 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 V1, 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.[2]
Procedures
ACC/AHA Class I indications[1] for performing cardiac catheterization
- 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.
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. Aug 1 2006;114(5):e84-231. [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].
[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].
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. Mar 2011;32(6):751-759. [Medline].
Feldman T, Cilingiroglu M. Percutaneous leaflet repair and annuloplasty for mitral regurgitation. J Am Coll Cardiol. Feb 1 2011;57(5):529-37. [Medline].
Feldman T, Foster E, Glower DG, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. Apr 14 2011;364(15):1395-406. [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. Oct 2011;97(20):1675-80. [Medline].
[Best Evidence] 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. Nov 17 2009;54(21):1961-8. [Medline].
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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. Mar 3 2005;352(9):875-83. [Medline].
Fann JI, Ingels NB, Miller DC. Pathophysiology of Mitral Valve Disease. In: 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. Oct 2005;22(9):748-69. [Medline].
Libby P, Bonow RO, MD, Zipes DP, Mann DL. Valvular Heart Disease. In: 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. 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].
Rosenhek R, Rader F, Klaar U, Gabriel H, Krejc M, Kalbeck D, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. May 9 2006;113(18):2238-44. [Medline].
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