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Mitral Regurgitation

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

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Aetiology

Mitral regurgitation occurs when the mitral valve does not close properly, allowing blood to leak backwards. The most common type is degenerative mitral regurgitation when rupture of chordae leads to prolapse of one or both leaflets.

Other causes are ischaemic (a rare early complication of inferior myocardial infarction usually, due to a ruptured papillary muscle, rheumatic, bacterial endocarditis, congenital heart disease, Marfan's syndrome1 and cardiomyopathy.2

Presentation

  • Acute mitral regurgitation leads to rapid pulmonary oedema which is life-threatening and requires emergency valve repair.
  • Chronic mitral regurgitation is well-tolerated but dilatation of the left ventricle eventually causes heart failure and breathlessness.

Auscultation reveals a pansystolic murmur at the apex.

Chronic mitral regurgitation may remain asymptomatic for many years but patients should be investigated before the onset of disabling dyspnoea.

Investigations

  • CXR may show an enlarged left atrium and left ventricle.3
  • ECG often shows a broad P wave of left atrial enlargement.
  • Echocardiography (trans-thoracic and trans-oesophageal) is essential to confirm the diagnosis and assess severity. All patients with mitral regurgitation should be quantitatively evaluated (even in the absence of symptoms), as the grade of severity determines prognosis.4 The grade (severity) is defined by the regurgitant jet into the left atrium. More accurate quantification may be achieved by combining Doppler scanning and echocardiography.

MITRAL REGURGITATION (OM574a.jpg)

Echocardiography identifies the structure, thickness and movement of the heart valves and heart muscle. It can identify a normal valve from a scarred, thickened, calcified or otherwise abnormal valve.

The additional use of Doppler scanning helps to identify abnormal leakage across heart valves as well as the degree of leakage. Unlike echocardiography, Doppler scan follows the direction and velocity of blood flow (rather than movement of the valve leaflets). Reversed blood direction is seen with leakages (increased forward velocity of flow in a particular pattern is seen in stenosis). The Doppler image above shows the reversed pattern of flow (below the line) during systole across the leaking mitral valve.

Complications

Management

  • Antibiotic prophylaxis for dental surgery is now no longer recommended following recent National Institute for Health and Clinical Excellence (NICE) guidance.5
  • Diuretics may improve breathlessness.
  • The aim is to monitor and operate before the onset of severe symptoms. Preoperative assessment involves a coronary angiography.
  • Angiotensin-converting enzyme (ACE) inhibitors may palliate LV dysfunction.
  • Anticoagulation for atrial fibrillation (target INR is 2-3).
  • Cardioversion - for recent-onset atrial fibrillation.
  • Valve repair has a lower mortality and a better long-term outcome than valve replacement, with no need for long-term anticoagulation; numerous techniques are available depending on the cause of the regurgitation (e.g. inserting new Teflon® chords). Percutaneous repair or annuloplasty are not yet routinely recommended.6,7
  • Valve replacement is needed for acute mitral regurgitation, severe chronic regurgitation, severe LV dysfunction (ejection fraction <30%) and most cases of rheumatic valve disease.

Follow-up

  • Asymptomatic patients should be followed up every 6-12 months with echocardiography.
  • More frequent follow-up is required if there is severe regurgitation, atrial fibrillation, pulmonary hypertension or LV impairment.

Prognosis

The best short-term and long-term results are obtained in asymptomatic patients operated on in specialist centres with low operative mortality (≤1%) and high repair rates (≥80-90%).2

Document references

  1. Taub CC, Stoler JM, Perez-Sanz T, et al; Mitral Valve Prolapse in Marfan Syndrome: An Old Topic Revisited. Echocardiography. 2008 Nov 24. [abstract]
  2. Enriquez-Sarano M, Akins CW, Vahanian A; Mitral regurgitation. Lancet. 2009 Apr 18;373(9672):1382-94. Epub 2009 Apr 6. [abstract]
  3. Ray S, Beynon R, Borg A. Mitral Valve Disease. Medicine 2006, Vol 34:6; pp 226-230
  4. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al; Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005 Mar 3;352(9):875-83. [abstract]
  5. Antimicrobial prophylaxis against infective endocarditis, NICE Clinical Guideline (March 2008)
  6. Percutaneous mitral valve leaflet repair for mitral regurgitation, NICE Interventional Procedure Guideline (August 2009)
  7. Percutaneous mitral valve annuloplasty, NICE Interventional Procedure Guideline (July 2010)

Internet and further reading

Acknowledgements

EMIS is grateful to Dr Hayley Willacy for writing this article and to Dr Peter Kaye and Dr Huw Thomas and Dr Richard Draper for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2011.
Document ID: 1232
Document Version: 22
Document Reference: bgp25302
Last Updated: 24 Mar 2011
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