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Subject: Mitral Regurgitation
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Disorder of mitral valve (MV) closure, either primary or secondary (functional), resulting in a backflow of the left ventricular (LV) stroke volume into the left atrium (LA); uncompensated, this leads to LV and LA enlargement, elevated pulmonary pressures, atrial fibrillation, heart failure, and sudden cardiac death
Types of mitral regurgitation (MR):
System(s) affected: cardiac; pulmonary
By severity on echocardiography:
By category 1
Acute MR: acute damage to MV leads to sudden LA and LV volume overload. Sudden rise in LV volume load without compensatory LV remodeling results in impaired forward cardiac output and possible cardiogenic shock.
Chronic MR: LV eccentric hypertrophy compensates for increased regurgitant volume to maintain forward cardiac output and alleviate pulmonary congestion. However, ongoing LV remodeling can result in LV dysfunction. Simultaneously, LA compensatory dilatation for the larger regurgitant volume predisposes patients to develop atrial fibrillation (AF).
Ischemic MR: papillary muscle rupture, ischemia during acute myocardial infarction (MI), and incomplete coaptation of valve leaflets or restricted valve movement resulting from ischemia
Risk factor modification for CAD
Antibiotic prophylaxis for poststreptococcal RHD
Endocarditis prophylaxis for MR is no longer recommended.
Associated conditions: RHD, prior MI, connective tissue disorder
Aortic stenosis (AS): usually midsystolic but can be long; difficult to distinguish from holosystolic, at apical area, and radiating to the carotid arteries (unlike MR)
Tricuspid regurgitation: holosystolic but at left lower sternal border; does not radiate to axilla or increase in intensity with inspiration (unlike MR)
Ventricular septal defect (VSD): harsh holosystolic murmur at lower left sternal border but radiates to right sternal border (not axilla)
Chest x-ray (CXR)
Cardiac enzymes and brain natriuretic peptide (BNP), if appropriate
Transthoracic echocardiogram (TTE)
Intervals for follow up TTE: See “Follow-Up Recommendations.”
Cardiovascular magnetic resonance (CMR):
Transesophageal echocardiogram (TEE)
Exercise hemodynamics with either doppler echo or cardiac catheterization 2[C]
Exercise treadmill testing 2[C]
Noninvasive imaging (stress nuclear/position emission tomography, CMR, stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary angiography
Left ventriculography and hemodynamic measurement
Coronary angiography: prior to MV surgery in patients at risk for CAD
Acute, severe MR
Isolated MV surgery is not indicated for patients with mild to moderate MR.
Acute, severe MR secondary to acute MI
Chronic severe MR
Medical therapy alone for patients >75 years of age with MR is preferred, owing to increased operative mortality and decreased survival (compared with those with AS), especially with preexisting CAD or need for MV replacement.
MV repair is preferable than MV replacement.
Mild MR with normal LV size and function and no pulmonary hypertension: Annual clinical evaluation to assess symptom progression and TTE every 3 to 5 years to assess MR severity, LV size and function.
Moderate MR: annual clinical evaluation and TTE every 1 to 2 years
Severe MR: clinical evaluation and TTE every 6 to 12 months
Consider serial CXRs and ECGs, and consider stress test if exercise capacity is doubtful.
Exercise after MV repair: Avoid sports with risk for bodily contact or trauma. Low-intensity competitive sports are allowed.
Competitive athletes with MR
AF and anticoagulation: no contact sports
Acute, severe MR: Mortality risk with surgery is 50%; mortality risk with medical therapy alone is 75% in first 24 hours and 95% at 2 weeks.
Chronic MR: asymptomatic severe MR with normal LVEF: 10% yearly rate of progression to symptoms and subnormal resting LVEF. Symptomatic severe MR: 8-year survival rate, 33% without surgery; mortality rate, 5% yearly
Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014;370(1):23–32.
Feldman T, Young A. Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 2014;63(20):2057–2068.
Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33(19):2451–2496.
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240–e327.
I34.0 Nonrheumatic mitral (valve) insufficiency
I05.1 Rheumatic mitral insufficiency
Q23.3 Congenital mitral insufficiency
424.0 Mitral valve disorders
394.1 Rheumatic mitral insufficiency
746.6 Congenital mitral insufficiency
48724000 Mitral valve regurgitation (disorder)
31085000 Rheumatic mitral regurgitation (disorder)
29928006 Congenital insufficiency of mitral valve (disorder)
373116009 Acute mitral regurgitation
194978002 Non-rheumatic mitral regurgitation (disorder)
Follow-up for mild to moderate MR: serial exam and/or echo unless LV structural changes
Severe MR is usually managed with MV repair.
Endocarditis prophylaxis is not recommended.