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Acute Mitral Regurgitation

  • Author: Daniel DiSandro, MD; Chief Editor: Barry E Brenner, MD, PhD, FACEP  more...
 
Updated: Dec 28, 2015
 

Background

Mitral regurgitation, in the acute and chronic decompensated states, is commonly encountered in the emergency department. An understanding of the underlying etiologies and pathophysiology of the condition is critical to direct appropriate treatment.

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Pathophysiology

Mitral regurgitation can be divided into the following 3 stages: acute, chronic compensated, and chronic decompensated.

In the acute stage, which usually occurs with a spontaneous chordae tendineae or papillary muscle rupture secondary to myocardial infarction, a sudden volume overload occurs on an unprepared left ventricle and left atrium. The volume overload on the left ventricle increases left ventricular stroke work. Increased left ventricular filling pressures, combined with the transfer of blood from the left ventricle to the left atrium during systole, results in elevated left atrial pressures. This increased pressure is transmitted to the lungs resulting in acute pulmonary edema and dyspnea.

If the patient tolerates the acute phase, the chronic compensated phase begins. The chronic compensated phase results in eccentric left ventricular hypertrophy. The combination of increased preload and hypertrophy produces increased end-diastolic volumes, which, over time, result in left ventricular muscle dysfunction. This muscle dysfunction impairs the emptying of the ventricle during systole. Therefore, regurgitant volume and left atrial pressures increase, leading to pulmonary congestion.

See the image below.

Severe mitral regurgitation as depicted with color Severe mitral regurgitation as depicted with color Doppler echocardiography.
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Epidemiology

Frequency

United States

Previously, chronic rheumatic heart disease was the most common cause of acquired mitral valve disease in the Western world. More recently, however, mitral valve prolapse (MVP) has become the most common cause, being responsible for 45% of cases of mitral regurgitation. MVP has been estimated to be present in 4% of the population; however, significant regurgitation in this population only occurs in those with abnormalities of the valve.

International

In areas other than the Western world, rheumatic heart disease remains the leading cause of mitral regurgitation.

Mortality/Morbidity

The prognosis of patients with mitral regurgitation depends on the underlying etiologies and the state of the left ventricular function. The extent of left ventricular dysfunction from underlying ischemia is the primary prognostic determinant in those with regurgitation secondary to coronary artery disease (CAD).

Consider the following:

  • Acute pulmonary edema and cardiogenic shock often complicate the course of acute regurgitation. The operative mortality in these cases approaches 80%. A patient with ruptured chordae tendineae and minimal symptoms has a much better prognosis.
  • With chronic regurgitation, volume overload is tolerated very well for years before symptoms of failure develop. Left atrial enlargement predisposes patients to the onset of atrial fibrillation with the subsequent complication of embolization. In addition, these patients are susceptible to endocarditis. A study of the survival of patients with chronic regurgitation was performed using randomly selected patients. The study revealed that 80% of the patients were alive 5 years later, and 60% were alive after 10 years.
  • Most patients with mitral valve prolapse are asymptomatic. Prolapse in those older than 60 years is frequently associated with chest pain, arrhythmias, and heart failure. The prognosis of these patients is good; however, sudden death, endocarditis, and progressive regurgitation occur rarely.
  • When ischemic heart disease is the mechanism for regurgitation, the extent of anatomic disease and left ventricular performance are prognostic determinants. Complicating events include sudden death and myocardial infarction.

Patients with acute mitral regurgitation secondary to infarction emergently requiring valve replacement have a 60-80% mortality rate if they present with severe pulmonary edema.

Major complications from chronic regurgitation include the following:

  • Severe LV dysfunction
  • Chronic congestive heart failure
  • Atrial fibrillation and its complications (eg, left atrial thrombus with embolization and stroke)
  • Sudden death, ruptured chordae tendineae, and endocarditis remain infrequent complications of regurgitation secondary to long-standing mitral prolapse.

Sex

In those younger than 20 years, males are affected more often than females. In those older than 20 years, no sexual predilection exists. Males older than 50 years are affected more severely.

Age

Of those cases caused by prior rheumatic disease, the mean age is 36, plus or minus 6 years.

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Contributor Information and Disclosures
Author

Daniel DiSandro, MD Clinical Assistant Professor, Department of Emergency Medicine, Drexel University College of Medicine

Daniel DiSandro, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Medical Association, Society for Academic Emergency Medicine

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.

Paul Blackburn, DO, FACOEP, FACEP Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, Arizona Medical Association, American College of Osteopathic Emergency Physicians, American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
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  8. Schon HR. Medical treatment of chronic valvular regurgitation. J Heart Valve Dis. 1995 Oct. 4 Suppl 2:S170-4. [Medline].

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Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.
Severe mitral regurgitation as depicted with color Doppler echocardiography.
Four-chamber apical view of a 2-dimensional transthoracic echocardiogram demonstrates mitral valve prolapse (MVP), a common cause of mitral regurgitation.
 
 
 
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