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  • Clinician

Mitral regurgitation (Mitral valve regurgitation)

Summary

Mitral regurgitation (MR) is the leakage of blood from the left ventricle into the left atrium due to incomplete closure of the mitral valve during systole. It is a common form of valvular disease and categorized according to onset (into acute and chronic forms) and etiology. Primary MR involves the structure of the mitral valve whereas secondary MR is a result of different pathologies that lead to valvular incompetence (e.g., cardiomyopathy). Ischemic MR can be acute (e.g., papillary muscle rupture in myocardial infarction) or chronic (in coronary artery disease). Symptoms vary from cardiogenic shock and flash pulmonary edema in acute manifestations to mild symptoms such as cough and dyspnea in chronic cases. Echocardiography is the diagnostic modality of choice; further imaging and treatment options are determined by the etiology. The definitive treatment in primary MR is surgical repair or valve replacement, while therapy of an underlying condition, e.g., percutaneous coronary intervention (PCI) in coronary artery disease, is the mainstay of therapy in secondary MR. Pharmacological treatment aims to reduce the degree of heart failure.

Etiology

Pathophysiology

References:[3][4]

Clinical features

Acute mitral regurgitation [5]

Chronic mitral regurgitation

Diagnostics

Transthoracic echocardiography (TTE) is used to confirm the diagnosis and classify severity in patients with suspected MR. Check ECG and troponin in acute MR to rule out myocardial infarct. Consider additional diagnostics (e.g., coronary angiography, blood cultures) depending on patient stability and the suspected underlying condition.

Classification

  • American Heart Association (AHA) staging for MR [9][10]
    • Used to monitor intervals and determine the need for interventions
    • Based on echocardiographic criteria of valve anatomy, hemodynamics, and associated cardiac findings (e.g., LV dilation)
    • Criteria vary between primary and secondary MR.
AHA staging for mitral valve regurgitation [9][10]
Stage Extent of mitral regurgitation
A
  • At risk of MR (minimal regurgitation)
B
  • Progressive MR (moderate regurgitation)
C1
  • Asymptomatic severe MR (LVEF > 60%)
C2
  • Asymptomatic severe MR (LVEF ≤ 60%)
D
  • Severe symptomatic MR
  • Carpentier classification
    • Uses echocardiography findings to classify leaflet motion (Carpentier types I–III). [1][11]
    • Used in the planning of surgical repair

Laboratory studies

Myocardial infarction must be ruled out in patients presenting with acute mitral regurgitation!

ECG

Echocardiography

  • Used to [6]
    • Assess the valve apparatus
    • Assess the size and function of the left ventricle and atrium
    • Grade the MR as mild, moderate, or severe
  • Procedure
    • TTE: modality of choice for the initial assessment of all patients with suspected valvular abnormality [6][5]
    • Transesophageal echocardiography (TEE): indicated prior to surgery and during the diagnostic workup of MR if TTE is inadequate [6][1]

Findings in primary mitral regurgitation [9][10][5]

Echocardiographic characteristics of primary mitral regurgitation
Parameter Acute MR Chronic MR
Valve movement or function
  • Abnormal
  • Abnormal
Aortic valve opening [15]
  • Decreased
  • Decreased
Pulmonary vein flow [16]
  • May be reversed
  • Generally normal
Left atrium
  • Normal
  • Dilated
Left ventricle size
  • Normal
  • Increased/remodeled
LVEF
  • Normal
  • Compensated: normal or increased [17]
  • Decompensated: decreased [18]
Pulmonary artery pressure [19][20]
  • Elevated
  • Compensated: normal
  • Decompensated: elevated
Right ventricle ejection fraction
  • Normal
  • Compensated: normal
  • Decompensated: reduced [19][21]

Findings in secondary mitral regurgitation [9][10]

Chest x-ray

  • Indications
  • Findings
    • Decompensated MR and acute MR: signs of pulmonary congestion (see x-ray findings in pulmonary congestion) [5][7]
    • Acute MR: normal-sized cardiac silhouette [5]
    • Chronic MR: Changes related to cardiac remodeling and associated heart failure may be visible.
      • LV enlargement: laterally displaced left cardiac border
      • LA enlargement: straightening of the left cardiac border and double density sign [22]
      • Annular calcification may be visible as a C-shaped density. [6]

Additional investigations

In primary MR, additional diagnostics should be considered if echocardiography does not allow for the adequate assessment of mitral valve function. In secondary MR, consider advanced diagnostics to determine the underlying condition (e.g., coronary artery disease).

Treatment

Acute mitral regurgitation

General principles

  • Management of acute MR is complex and cardiology and cardiothoracic surgery should be consulted as early as possible.
  • All patients with acute primary MR should undergo urgent surgical repair or valve replacement.
  • While awaiting surgery, any symptoms of heart failure should be managed with medical therapy (e.g., diuretics, nitrates, antihypertensive drugs).
  • If secondary MR is suspected, identify and treat the underlying cause (e.g., revascularization therapy for ischemic MR) [11]

Surgical therapy [5]

All patients with acute primary MR should undergo urgent surgical repair or valve replacement.

Medical therapy

For acute primary MR, medical treatment is usually only a temporizing measure while surgery is planned. The aim is to reduce the symptoms of heart failure and improve forward flow.

Heart failure treatment may worsen hypotension; use caution in hemodynamically unstable patients.

Bridging devices

  • Indications
    • Patients whose symptoms continue to deteriorate despite medical therapy [31]
    • Unstable patients prior to surgery
  • Procedures
    • Intra-aortic balloon pump (IABP) [5][31]
    • Consider left ventricular assist device (LVAD) or ECMO in patients who are deteriorating despite pharmacological therapy and IABP. [7]

Chronic mitral regurgitation

Management of chronic MR is guided by the symptoms and extent of heart failure and the cause of MR. Medical therapy should be initiated in all patients to optimize cardiac function but surgery is the definitive treatment option.

Medical management

Surgical management and transcatheter mitral repair

  • Chronic primary MR
    • Indications [9][1]
      • Asymptomatic patients with LV dysfunction (LVEF 30–60%; or LV end-systolic diameter ≥ 40 mm) (stage C2)
      • Symptomatic patients with LVEF 30–60 % (stage D)
    • Contraindications: Once LVEF is < 30%, surgery is generally not recommended because of the high mortality rate and low likelihood of symptom improvement. [11]
    • Procedure
      • Valve repair is preferred to replacement because it is associated with reduced mortality and fewer complications. [25]
      • Transcatheter mitral valve procedures, such as a clip device, can be considered in patients who are considered to be unsuitable for surgical repair and severely symptomatic. [1]
  • Chronic secondary MR [9] [6]
    • Indications: consider for patients with severe MR and persistent symptomatic heart failure (NYHA classes III–IV) despite optimal medical management [9]
    • Procedure:

Complications

We list the most important complications. The selection is not exhaustive.

Acute management checklist for acute mitral regurgitation

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last updated 08/26/2020
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