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1 Chapter 1 : Mitral Regurgitation Mitral valve regurgitation â also called mitral regurgitation, mitral insufficiency or mitral incompetence â is a condition in which your heart's mitral valve doesn't close tightly, allowing blood to flow backward in your heart. Mitral Valve Prolapse Mitral Regurgitation Acute mitral regurgitation may result from chordae tendineae rupture, papillary muscle rupture or dysfunction in patients with acute coronary syndrome, myxomatous degeneration pathologic weakening of the valve associated with accumulation of glycosaminoglycans, infective endocarditis, trauma, or acute myocardial ischemia. Mitral valve prolapse currently is the most common cause of chronic disease, followed by ischemic mitral valve disease and damage from infective endocarditis. Mitral annular calcification is a common cause of mitral regurgitation in older patients, whereas rheumatic heart disease is now a relatively uncommon cause. Diagnosis Acute, severe mitral regurgitation causes abrupt onset of dyspnea, pulmonary edema, or cardiogenic shock. Physical findings may include hypotension, an apical holosystolic murmur radiating to the axilla the murmur may be short or absent, an S3 or S4 gallop, pulmonary crackles, and signs of right-sided heart failure eg, jugular venous distention, hepatomegaly, edema. Chronic mitral regurgitation results in exercise intolerance, dyspnea, or fatigue. Physical findings include brisk carotid upstrokes, a laterally displaced apical impulse, decreased intensity of S1, increased intensity of P2, a widely split S2 during inspiration, and an S3 gallop. The holosystolic murmur is best heard with the diaphragm at the apex, with the patient in the left lateral decubitus position; the murmur may radiate to the left axilla and left scapular region. In advanced cases, chest radiographs may reveal cardiomegaly and pulmonary vascular congestion. An ECG may demonstrate an abnormal rhythm ie, atrial fibrillation and findings consistent with left atrial enlargement and left ventricular hypertrophy. Doppler echocardiography allows for assessment of left atrial and left ventricular volumes, ejection fraction, and other valvular disease. The left ventricular ejection fraction may be normal or falsely elevated due to systolic ejection of a portion of left ventricular volume into the low-pressure left atrium. Therapy Repair or replacing the mitral valve is indicated in symptomatic patients with acute disease. Vasodilators eg, sodium nitroprusside, nitroglycerin and diuretics reduce pulmonary congestion and improve forward cardiac output. An inotropic agent dobutamine may be used if hypotension develops. Intra-aortic balloon counterpulsation can improve coronary perfusion and reduce afterload in hemodynamically unstable patients as a bridge to valve replacement. In long-term disease, survival depends on left ventricular function, and surgery is most effective prior to the development of heart failure, atrial fibrillation, and pulmonary hypertension. Valve repair has advantages over replacement, including the avoidance of anticoagulants and future mechanical valve complications or failure. A percutaneously placed clip that focally approximates the edges of the mitral valve leaflets to reduce regurgitation is available for patients considered too frail to tolerate surgery. Anticoagulants and atrioventricular nodal blocking agents are used in patients with atrial fibrillation. Follow-Up Annual history, physical examination, and echocardiography are appropriate for patients with mild disease. More frequent monitoring is indicated for advanced disease. Patients with evidence of progressive left ventricular dysfunction require surgical intervention. Page 1

2 Chapter 2 : Mitral Insufficiency - UAB Medicine Mitral regurgitation is increasingly prevalent. Doppler echocardiography not only detects the presence of regurgitation but also permits to understand mechanisms of regurgitation, quantification of its severity, and repercussions. Chambers and valves of the heart Chambers and valves of the heart A normal heart has two upper and two lower chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of your heart. The heart valves, which keep blood flowing in the right direction, are gates at the chamber openings. Your heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps leaflets or cusps that open and close once during each heartbeat. Mitral valve prolapse and regurgitation Mitral valve prolapse and regurgitation The mitral valve separates the two chambers atrium and ventricle of the left side of the heart. Sometimes mitral valve prolapse causes blood to leak back into the atrium from the ventricle, which is called mitral valve regurgitation. Mitral valve regurgitation causes Mitral valve regurgitation can be caused by problems with the mitral valve, also called primary mitral valve regurgitation. Diseases of the left ventricle can lead to secondary or functional mitral valve regurgitation. Possible causes of mitral valve regurgitation include: This common heart defect can prevent the mitral valve from closing tightly and lead to regurgitation. Over time, the tissue cords that anchor the flaps of the mitral valve to the heart wall may stretch or tear, especially in people with mitral valve prolapse. A tear can cause leakage through the mitral valve suddenly and may require repair by heart surgery. Trauma to the chest also can rupture the cords. Rheumatic fever â a complication of untreated strep throat â can damage the mitral valve, leading to mitral valve regurgitation early or later in life. The mitral valve may be damaged by an infection of the lining of the heart endocarditis that can involve heart valves. A heart attack can damage the area of the heart muscle that supports the mitral valve, affecting the function of the valve. If the damage is extensive enough, a heart attack can cause sudden and severe mitral valve regurgitation. Abnormality of the heart muscle cardiomyopathy. This can stretch the tissue around your mitral valve, which can lead to leakage. Experiencing trauma, such as in a car accident, can lead to mitral valve regurgitation. Some babies are born with defects in their hearts, including damaged heart valves. Prolonged use of certain medications can cause mitral valve regurgitation, such as those containing ergotamine Cafergot, Migergot that are used to treat migraines and other conditions. In rare cases, radiation therapy for cancer that is focused on the chest area can lead to mitral valve regurgitation. Atrial fibrillation is a common heart rhythm problem that can be a potential cause of mitral valve regurgitation. Risk factors Several factors can increase your risk of mitral valve regurgitation, including: A history of mitral valve prolapse or mitral valve stenosis. A family history of valve disease also can increase risk. A heart attack can damage your heart, affecting the function of the mitral valve. Certain forms of heart disease, such as coronary artery disease, can lead to mitral valve regurgitation. Use of certain medications. People who take drugs containing ergotamine Cafergot, Migergot and similar medicines for migraines or who take cabergoline have an increased risk of mitral regurgitation. Similar problems were noted with the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold. Infections such as endocarditis or rheumatic fever. Infections or the inflammation they cause can damage the mitral valve. Some people are born with an abnormal mitral valve prone to regurgitation. By middle age, many people have some mitral valve regurgitation caused by natural deterioration of the valve. However, severe mitral valve regurgitation can lead to complications, including: Severe mitral valve regurgitation places an extra strain on the heart because, with blood pumping backward, there is less blood going forward with each beat. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure. Also, pressure builds in your lungs, leading to fluid accumulation, which strains the right side of the heart. Atrial fibrillation can cause blood clots, which can break loose from your heart and travel to other parts of your body, causing serious problems, such as a stroke if a clot blocks a blood vessel in your brain. If you have long-term untreated or improperly treated mitral regurgitation, you can develop a type of high blood pressure that affects the vessels in the lungs pulmonary hypertension. A leaky mitral valve can Page 2

3 increase pressure in the left atrium, which can eventually cause pulmonary hypertension. This can lead to heart failure on the right side of the heart. Page 3

4 Chapter 3 : Mitral valve regurgitation - Symptoms and causes - Mayo Clinic Mitral regurgitation is the most common type of heart valve disorder. Blood that flows between different chambers of your heart must flow through a valve. The valve between the 2 chambers on the left side of your heart is called the mitral valve. Mitral valve regurgitation; Mitral valve insufficiency; Heart mitral regurgitation; Valvular mitral regurgitation Share Mitral regurgitation is a disorder in which the mitral valve on the left side of the heart does not close properly. Regurgitation means leaking from a valve that does not close all the way. The interior of the heart is composed of valves, chambers, and associated vessels. The external structures of the heart include the ventricles, atria, arteries and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide. There are four valves in the heart aortic valve, mitral valve, tricuspid valve, and pulmonary valve. The valves are designed to control the direction of blood flow through the heart. The opening and closing of the heart valves produce the heart-beat sounds. General overview of heart valve disorders, including types, basics about how valves work, causes and treatments. Causes Mitral regurgitation is the most common type of heart valve disorder. Blood that flows between different chambers of your heart must flow through a valve. The valve between the 2 chambers on the left side of your heart is called the mitral valve. This cuts down on the amount of blood that flows to the rest of the body. As a result, the heart may try to pump harder. This may lead to congestive heart failure. Mitral regurgitation may begin suddenly. This often occurs after a heart attack. When the regurgitation does not go away, it becomes long-term chronic. Many other diseases or problems can weaken or damage the valve or the heart tissue around the valve. You are at risk for mitral valve regurgitation if you have: Coronary heart disease and high blood pressure Infection of the heart valves Rare conditions, such as untreated syphilis or Marfan syndrome Rheumatic heart disease. This is a complication of untreated strep throat that is becoming less common. Swelling of the left lower heart chamber Another important risk factor for mitral regurgitation is past use of a diet pill called "Fen-Phen" fenfluramine and phentermine or dexfenfluramine. The drug was removed from the market by the U. Symptoms Symptoms may begin suddenly if: A heart attack damages the muscles around the mitral valve. The cords that attach the muscle to the valve break. An infection of the valve destroys part of the valve. There are often no symptoms. When symptoms occur, they often develop gradually, and may include: Page 4

5 Chapter 4 : Mitral valve regurgitation: MedlinePlus Medical Encyclopedia Mitral regurgitation is leakage of blood backward through the mitral valve each time the left ventricle contracts. Watch an animation of mitral valve regurgitation. A leaking mitral valve allows blood to flow in two directions during the contraction. Reprinted with permission from Elsevier. Diagnosis by echocardiography is the standard technique by which to confirm VHD, as well as determine disease severity and prognosis. Echocardiography evaluates valve structure and function Bonow et al. Valve replacement or repair performed either surgically or by catheter intervention are the only effective therapies. Mortality risk with such intervention ranges from 1 to 20 percent and can be as high as 30 percent depending on circumstances, including the presence of other cardiac conditions, the skill of the surgeon, age of the patient, and the presence of a host of comorbidities including lung, kidney, and neurological disease. Approximately, patients have valve disease that becomes serious enough to warrant some level of disability. Of those, roughly 80, a year undergo heart surgery to repair or replace defective valves. Once it is determined that the patient has severe symptomatic VHD, the algorithm in Figure should be used to determine disability. Updating the Social Security Listings. The National Academies Press. Patients with this condition should not perform manual work, because it is possible that they could experience sudden death on the job. Disability is determined on the basis of the presence of severe anatomic valve disease determined by echocardiography or other appropriate medical imaging and the symptoms caused by it. The committee concludes it is reasonable to provide disability at the listing level to symptomatic patients with severe valve disease, including aortic stenosis, mitral stenosis, aortic regurgitation, and mitral regurgitation. Unlike other cardiac impairments, determining disability using measurements of functional criteria is not advised for symptomatic individuals with severe aortic stenosis, because there is risk to the patient in performing exercise tests. Furthermore, the severity of disease for patients with severe symptomatic aortic stenosis is sufficient to grant disability at the listing level without other indications of functional limitation, such as evidence of related heart failure. Provide a listing-level pathway to disability for symptomatic claimants with objective evidence via echocardiogram or other appropriate medically acceptable imaging of severe aortic stenosis, characterized by mean gradient greater than 40 mm Hg, jet velocity greater than 4. Severe mitral stenosis, aortic regurgitation, or mitral regurgitation may also warrant disability at the listing level, but these patients must demonstrate functional limitation in addition to an objective diagnosis of severity. Individuals with moderate or mild valve disease may still be disabled by their impairment, however, but the committee agrees these impairments would not warrant disability at the listing level. Provide a listing-level pathway to disability for symptomatic claimants with objective evidence via echocar- Page Share Cite Suggested Citation: Objective evidence is measured by one of the following: Severe mitral stenosis characterized by mean gradient greater than 10 mm Hg, pulmonary artery systolic pressure greater than 50 mm Hg, and valve area less than 1. Functional limitation s from severe mitral stenosis, aortic regurgitation, or mitral regurgitation would be demonstrated by one of the following: Three hospitalizations with heart failure in 12 months; or Inability to achieve 5 metabolic equivalents of task on an exercise test; or Objective evidence of right heart failure. For example, an individual may undergo medical testing revealing results that meet the recommended listing, but then receive treatment and on further testing, no longer meet the disability criteria at the listing level. The most common example of this scenario for VHD would be valve replacement or repair. An applicant with evidence of severe symptomatic valve disease may undergo surgery with complete resolution of symptoms and no functional limitations. Page Share Cite Suggested Citation: Journal of the American College of Cardiology 48 3: Page 5

6 Chapter 5 : Mitral valve regurgitation Information Mount Sinai - New York Mitral Valve prolapse: One or both mitral leaflets are due to Mitral valve prolapse with regurgitation Needs prophylactic antibiotics prior to dental or surgical procedures. Mitral annular calcification MAC is common in elderly patients and leaflet tips and chordae can thicken, but these infrequently cause clinically important stenosis. MAC and calcific aortic stenosis are often associated. This patient was tachycardic, making analysis more difficult. This patient also had calcification and restricted movement of the aortic valve and the left atrium LA was enlarged. This next patient was not tachycardic, which makes it easier to see both the restricted movement of the MV and the thickening and calcification, particularly of the posterior leaflet apparatus. As with the first patient, the aortic valve was also calcified and the LA was enlarged. A final patient had thickening and sclerosis of the anterior leaflet, but it was only mildly restricted in movement, with an EPSS of 0. The aortic valve was sclerotic but opened fairly well. The LA was certainly enlarged. The key indicator is color flow Doppler CF in the apical views. It is appropriate to look for this in the apical4, apical2, and apical3 views because they each look at the LV inflow jet from a different angle. Here is an apical CF clip from a clinic patient with heavy calcification of the MV and apparent restricted leaflet movement. The jet toward the LV was heavily aliased, rather than the usual red flush. With a strongly aliased mitral inflow signal, continuous wave Doppler can evaluate the E wave. In rheumatic MS, the E velocity is high and never returns to the baseline off of the E. Here is a tracing from a clinic patient with rheumatic MS. Notice the high E-peak velocity of 2. Compare this rheumatic MS tracing to the mitral inflow tracing done with pulse wave Doppler in the previous MAC patient. The shape of this spectrum looks similar, with the velocity never returning to the baseline. However, the measured peak E velocity was only 0. Unless the PWD gate was sub-optimally positioned in the mitral inflow or the patient was in a very low cardiac output state, such a low velocity indicates clinically insignificant MS. But, it is a cause of mitral regurgitation, heart failure, infective endocarditis, and stroke. There are various genetic predispositions that can lead to MVP. Once MR is present, follow-up needs to be more frequent because the progression of the MR and the consequences for the heart cannot be predicted. Ruptured chordal structures and even flail leaflets are definite possibilities. In addition, as MR becomes significant, the risk of endocarditis becomes higher in relative terms but still very low in absolute terms. The ID and Cardiology societies recommendations against prophylaxis for MVP are based on older population estimates considering whether an MR murmur was heard or not. The presence or absence of a murmur is a poor surrogate for the severity of MR. Nevertheless, since the absolute incidence of endocarditis in MVP with even severe MR is probably not greater than 1 in, the societies recommendations against antibiotic prophylaxis probably make sense for most patients, but it is justified to worry about an MVP patient with substantial MR. The whole valve apparatus in the PLAX and apical views should be evaluated. MVP should have increased thickening of the mitral leaflets and the sub-valvular apparatus without sclerosis. The chordae may also be floppy and elongated. A final characteristic feature is a rocking motion of the posterior-lateral mitral annulus. The following is a clip from sonography that is over a minute long, but nicely demonstrates these features in two different patients. There is no audio, but the arrow points to the characteristic things: These are more important than bowing of a leaflet back towards the LA. This is a pattern recognition diagnosis after enough normal mitral valves have been seen. If a patient has just a little bowing but no thickness or excess tissue in the whole valve apparatus and there is no MR, we should be reluctant to label the patient with MVP and should rarely recommend formal echocardiography. Acute MR would almost never be seen in the clinic because these patients become acutely ill very quickly. The rest of this section focuses on chronic MR. Chronic MR, as it progresses, is a volume overload on the LV, and the intermediate consequence is a somewhat hyper-contractile LV that eventually begins to dilate. Eventually, LA pressure increase is persistent and LA dilation and secondary pulmonary hypertension develop. In the final phase, LV function decreases and cannot keep up with the excess volume. The valve must be fixed before LV function drops below normal. LV radial function always looks visually better than it is because of the reduced afterload created by the MR and LV function after MV repair or replacement almost always deteriorates Page 6

7 because the after-load acutely increases. Quantification of MR is otherwise done equivalently to AR, looking for the presence and size of the flow convergence zone, the width of the vena contracta, and the length and width of the jet. The MR must be viewed in several planes because jets can be eccentric. Eccentric jets that are wall-huggers Coanda effect always appear less severe than they are unless the most proximal part of the jet is analyzed. Here is a table to help assess MR severity. Page 7

8 Chapter 6 : Mitral insufficiency - Wikipedia In primary mitral regurgitation (MR), the leak in the mitral valve causes hemodynamic overload of the left ventricle, damaging the ventricle and leading to heart failure and eventual death if the leak isn't corrected. URL of this page: Regurgitation means leaking from a valve that does not close all the way. Causes Mitral regurgitation is the most common type of heart valve disorder. Blood that flows between different chambers of your heart must flow through a valve. The valve between the 2 chambers on the left side of your heart is called the mitral valve. This cuts down on the amount of blood that flows to the rest of the body. As a result, the heart may try to pump harder. This may lead to congestive heart failure. Mitral regurgitation may begin suddenly. This often occurs after a heart attack. When the regurgitation does not go away, it becomes long-term chronic. Many other diseases or problems can weaken or damage the valve or the heart tissue around the valve. You are at risk for mitral valve regurgitation if you have: Coronary heart disease and high blood pressure Infection of the heart valves Rare conditions, such as untreated syphilis or Marfan syndrome Rheumatic heart disease. This is a complication of untreated strep throat that is becoming less common. Swelling of the left lower heart chamber Another important risk factor for mitral regurgitation is past use of a diet pill called "Fen-Phen" fenfluramine and phentermine or dexfenfluramine. The drug was removed from the market by the U. Symptoms Symptoms may begin suddenly if: A heart attack damages the muscles around the mitral valve. The cords that attach the muscle to the valve break. An infection of the valve destroys part of the valve. There are often no symptoms. When symptoms occur, they often develop gradually, and may include: Page 8

9 Chapter 7 : Mitral regurgitation - WikEM Mitral annular calcification is a common cause of mitral regurgitation in older patients, whereas rheumatic heart disease is now a relatively uncommon cause. Diagnosis Acute, severe mitral regurgitation causes abrupt onset of dyspnea, pulmonary edema, or cardiogenic shock. Received Jan 12; Accepted Apr This article has been cited by other articles in PMC. Abstract Background Functional tricuspid regurgitation TR occurs in patients with rheumatic mitral valve disease even after mitral valve surgery. The aim of this study was to analyze surgical results of TR after previous successful mitral valve surgery. Methods From September to September, 45 patients with TR after previous mitral valve replacement underwent second operation for TR. In those, 43 patients Tricuspid valve replacement was performed in 34 cases Postoperative low cardiac output LCO occurred in 5 patients and treated successfully. Postoperative echocardiography showed obvious reduction of right atrium and ventricle. The anterioposterior diameter of the right ventricle decreased to Conclusion TR after mitral valve replacement in rheumatic heart disease is a serious clinical problem. If it occurs or progresses late after mitral valve surgery, tricuspid valve annuloplasty or replacement may be performed with satisfactory results. Due to the serious consequence of untreated TR, aggressive treatment of existing TR during mitral valve surgery is recommended. Tricuspid regurgitation, Annuloplasty, Tricuspid valve replacement, Mitral valve surgery, Rheumatic heart disease Background Mitral valve replacement MVR has been the most common surgical procedure for rheumatic mitral valve disease including stenosis and incompetence. Functional tricuspid regurgitation TR is frequently associated with rheumatic mitral valve disease in the patients undergoing MVR. In addition, in patients who had previous mitral valve replacement, TR is also a frequently encountered complication. Which patient undergoing mitral valve surgery should also have the tricuspid repair is an important clinical question [ 1 ]. Most recently, Rogers and associates [ 3 ] suggested that if untreated at the time of surgical mitral valve repair, significant residual TR negatively impacts perioperative outcomes, functional class, and survival and that TR does not reliably resolve after successful mitral valve surgery. Further, if present at the time of mitral valve surgery, TR can usually be effectively addressed with ring annuloplasty. Because reoperations for recurrent TR carry high mortality rates, few patients are offered reoperation for redo tricuspid repair or replacement. We therefore, in the present study, report our experience in surgical treatment of TR post-mitral surgery. Methods Clinical data From September to September, a consecutive series of 45 patients who had second operation for TR after mitral valve replacement in the TEDA International Cardiovascular Hospital and previously incorporated hospitals were retrospectively enrolled in this study. The patients who had concomitant surgery apart from mitral valve replacement at the first operation or during the second operation for the TR were excluded from the present study. There were 12 male All patients were diagnosed rheumatic heart disease. Only 5 patients were in sinus rhythm Patients who had severe TR by echocardiography 24 patients, The average time from the pervious operation was 6. The previous operations included: All patients were investigated preoperatively by means of Doppler echocardiography. Echocardiography showed moderate TR in 21 cases The systolic pressure of pulmonary artery was Page 9

10 Chapter 8 : Mitral valve regurgitation - Oxford Medicine Mitral valve regurgitation (MR) When the mitral valve leaks, blood travels back towards the left atrium and lungs as the left ventricle contracts. This means that less blood is pumped around the body with each contraction of the heart. Signs and symptoms[ edit ] Phonocardiograms from normal and abnormal heart sounds The symptoms associated with MR are dependent on which phase of the disease process the individual is in. Individuals with acute MR are typically severely symptomatic and will have the signs and symptoms of acute decompensated congestive heart failure i. Cardiovascular collapse with shock cardiogenic shock may be seen in individuals with acute MR due to papillary muscle rupture, rupture of a chorda tendinea or infective endocarditis of the mitral valve. Individuals with chronic compensated MR may be asymptomatic for long periods of time, with a normal exercise tolerance and no evidence of heart failure. Over time, however, there may be decompensation and patients can develop volume overload congestive heart failure. Symptoms of entry into a decompensated phase may include fatigue, shortness of breath particularly on exertion, and leg swelling. Also there may be development of an irregular heart rhythm known as atrial fibrillation. The mitral component of the first heart sound is usually soft and with a laterally displaced apex beat, [3] often with heave. The loudness of the murmur does not correlate well with the severity of regurgitation. It may be followed by a loud, palpable P2, [3] heard best when lying on the left side. Cases with a late systolic regurgitant murmur may still be associated with significant hemodynamic consequences. The mitral valve apparatus comprises two valve leaflets, the mitral valve annulus, which forms a ring around the valve leaflets, and the papillary muscles, which tether the valve leaflets to the left ventricle and prevent them from prolapsing into the left atrium. The chordae tendineae are also present and connect the valve leaflets to the papillary muscles. Dysfunction of any of these portions of the mitral valve apparatus can cause regurgitation. Myxomatous degeneration of the mitral valve is more common in women as well as with advancing age, which causes a stretching of the leaflets of the valve and the chordae tendineae. Such elongation prevents the valve leaflets from fully coming together when the valve closes, causing the valve leaflets to prolapse into the left atrium, thereby causing MI. Ischemic heart disease causes MR by the combination of ischemic dysfunction of the papillary muscles, and the dilatation of the left ventricle. This can lead to the subsequent displacement of the papillary muscles and the dilatation of the mitral valve annulus. MR and mitral valve prolapse are also common in Ehlersâ Danlos syndromes. This dilatation of the left ventricle can be due to any cause of dilated cardiomyopathy including aortic insufficiency, nonischemic dilated cardiomyopathy, and Noncompaction cardiomyopathy. Because the papillary muscles, chordae, and valve leaflets are usually normal in such conditions, it is also called functional mitral insufficiency. The left ventricle develops volume overload because with every contraction it now has to pump out not only the volume of blood that goes into the aorta the forward cardiac output or forward stroke volume but also the blood that regurgitates into the left atrium the regurgitant volume. The combination of the forward stroke volume and the regurgitant volume is known as the total stroke volume of the left ventricle. In the acute setting, the stroke volume of the left ventricle is increased increased ejection fraction ; this happens because of more complete emptying of the heart. However, as it progresses the LV volume increases and the contractile function deteriorates, thus leading to dysfunctional LV and a decrease in ejection fraction. The regurgitant volume causes a volume overload and a pressure overload of the left atrium and the left ventricle. The increased pressures in the left side of the heart may inhibit drainage of blood from the lungs via the pulmonary veins and lead to pulmonary congestion. Compensated[ edit ] If the MR develops slowly over months to years or if the acute phase cannot be managed with medical therapy, the individual will enter the chronic compensated phase of the disease. In this phase, the left ventricle develops eccentric hypertrophy in order to better manage the larger than normal stroke volume. The eccentric hypertrophy and the increased diastolic volume combine to increase the stroke volume to levels well above normal so that the forward stroke volume forward cardiac output approaches the normal levels. In the left atrium, the volume overload causes enlargement of the left atrium, allowing the filling pressure in the left atrium to decrease. This improves the drainage from the pulmonary veins, and signs and symptoms of pulmonary congestion will decrease. These Page 10

11 changes in the left ventricle and left atrium improve the low forward cardiac output state and the pulmonary congestion that occur in the acute phase of the disease. Individuals in the chronic compensated phase may be asymptomatic and have normal exercise tolerances. Decompensated[ edit ] An individual may be in the compensated phase of MR for years, but will eventually develop left ventricular dysfunction, the hallmark for the chronic decompensated phase of mitral insufficiency. It is currently unclear what causes an individual to enter the decompensated phase of this disease. However, the decompensated phase is characterized by calcium overload within the cardiac myocytes. In this phase, the ventricular myocardium is no longer able to contract adequately to compensate for the volume overload of mitral regurgitation, and the stroke volume of the left ventricle will decrease. The decreased stroke volume causes a decreased forward cardiac output and an increase in the end-systolic volume. The increased end-systolic volume translates to increased filling pressures of the left ventricle and increased pulmonary venous congestion. The individual may again have symptoms of congestive heart failure. The left ventricle begins to dilate during this phase. This causes a dilatation of the mitral valve annulus, which may worsen the degree of MI. The dilated left ventricle causes an increase in the wall stress of the cardiac chamber as well. While the ejection fraction is less in the chronic decompensated phase than in the acute phase or the chronic compensated phase, it may still be in the normal range i. A decreased ejection fraction in an individual with mitral insufficiency and no other cardiac abnormality should alert the physician that the disease may be in its decompensated phase. Diagnosis[ edit ] There are many diagnostic tests that have abnormal results in the presence of MI. These tests suggest the diagnosis of MR and may indicate to the physician that further testing is warranted. For instance, the electrocardiogram ECG in long-standing MR may show evidence of left atrial enlargement and left ventricular hypertrophy. Atrial fibrillation may also be noted on the ECG in individuals with chronic mitral regurgitation. Comparison of acute and chronic phases of mitral insufficiency Acute. Page 11

12 Chapter 9 : Mitral Regurgitation News racedaydvl.com Mitral valve regurgitation treatment depends on how severe your condition is, if you're experiencing signs and symptoms, and if your condition is getting worse. The goal of treatment is to improve your heart's function while minimizing your signs and symptoms and avoiding future complications. Print Diagnosis Your doctor will ask about your medical history and your family history of heart disease. Your doctor will also perform a physical exam that includes listening to your heart with a stethoscope. Mitral valve regurgitation usually produces a sound of blood leaking backward through the mitral valve heart murmur. Your doctor will then decide which tests are needed to make a diagnosis. For testing, you may be referred to a cardiologist. Tests An echocardiogram is conducted. Common tests to diagnose mitral valve regurgitation include: This test is commonly used to diagnose mitral valve regurgitation. In this test, sound waves directed at your heart from a wandlike device transducer held on your chest produce video images of your heart in motion. This test assesses the structure of your heart, the mitral valve and the blood flow through your heart. Doctors also may use a 3-D echocardiogram. Doctors may conduct another type of echocardiogram called a transesophageal echocardiogram. In this test, a small transducer attached to the end of a tube is inserted down your esophagus, which allows a closer look at the mitral valve than a regular echocardiogram does. Wires electrodes attached to adhesive pads on your skin measure electrical impulses from your heart. An ECG can detect enlarged chambers of your heart, heart disease and abnormal heart rhythms. This enables your doctor to determine whether the left atrium or the left ventricle is enlarged â possible indicators of mitral valve regurgitation â and the condition of your lungs. A cardiac MRI uses magnetic fields and radio waves to create detailed images of your heart. This test may be used to determine the severity of your condition and assess the size and function of your lower left heart chamber left ventricle. Exercise tests or stress tests. If you are unable to exercise, medications to mimic the effect of exercise on your heart may be used. This invasive technique involves threading a thin tube catheter through a blood vessel in your arm or groin to an artery in your heart and injecting dye through the catheter to make the artery visible on an X-ray. This provides a detailed picture of your heart arteries and how your heart functions. It can also measure the pressure inside the heart chambers. A doctor trained in heart disease cardiologist will provide your care. If you have mitral valve regurgitation, consider being treated at a medical center with a multidisciplinary team of doctors and medical staff trained and experienced in evaluating and treating heart valve disease. This team can work closely with you to determine the most appropriate treatment for your condition. Watchful waiting Some people, especially those with mild regurgitation, might not need treatment. However, the condition may require monitoring by your doctor. You may need regular evaluations, with the frequency depending on the severity of your condition. Your doctor may also recommend making healthy lifestyle changes. These medications can relieve fluid accumulation in your lungs or legs, which can accompany mitral valve regurgitation. These medications can help prevent blood clots and may be used if you have atrial fibrillation. High blood pressure medications. High blood pressure makes mitral valve regurgitation worse, so if you have high blood pressure, your doctor may prescribe medication to help lower it. Surgery Your mitral valve may need to be repaired or replaced. If you need surgery for another heart condition, your doctor may repair or replace the diseased mitral valve at the same time. Mitral valve surgery is usually performed through a cut incision in the chest. In some cases, doctors may conduct minimally invasive heart surgery, which involves the use of smaller incisions than those used in open-heart surgery. Doctors at some medical centers may perform robot-assisted heart surgery, a type of minimally invasive heart surgery. In this type of surgery, surgeons view the heart in a magnified high-definition 3-D view on a video monitor and use robotic arms to duplicate specific maneuvers used in open-heart surgeries. Your doctor will discuss with you whether mitral valve repair or mitral valve replacement may be most appropriate for your condition. Doctors often may recommend mitral valve repair, as it preserves your own valve and may preserve heart function. Mitral valve repair Mitral valve repair In mitral valve repair, the surgeon removes and repairs part of the damaged mitral valve to allow the valve to fully close and stop leaking. The surgeon may tighten or reinforce the ring around a valve annulus by Page 12

13 implanting an artificial ring annuloplasty band. Then a doctor sutures together the edges and cinches the circumference of the valve with an annuloplasty band to support the valve, as shown in the bottom image. The illustration shows mitral valve repair using robotic instruments. Mitral valve repair Surgeons can repair the valve by reconnecting valve flaps leaflets, replacing the cords that support the valve, or removing excess valve tissue so that the leaflets can close tightly. Surgeons may often tighten or reinforce the ring around a valve annulus by implanting an artificial ring annuloplasty band. Doctors may use long, thin tubes catheters to repair the mitral valve in some cases. In one catheter procedure, doctors insert a catheter with a clip attached in an artery in the groin and guide it to the mitral valve. Doctors use the clip to reshape the valve. In another procedure, doctors may repair a previously replaced mitral valve that is leaking by inserting a device to plug the leak. In mitral valve replacement, your surgeon removes the damaged valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue biological tissue valve. Biological tissue valves degenerate over time, and often eventually need to be replaced. People with mechanical valves need to take blood-thinning medications for life to prevent blood clots. Your doctor can discuss the risks and benefits of each type of heart valve with you and discuss which valve may be appropriate for you. Doctors continue to study catheter procedures to repair or replace mitral valves. A catheter procedure can also be used to insert a replacement valve in a biological tissue replacement valve that is no longer working properly. Talk to your doctor about what type of follow-up you need after surgery, and let your doctor know if you develop new symptoms or if your symptoms worsen after treatment. Request an Appointment at Mayo Clinic Clinical trials Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this disease. Lifestyle and home remedies Your doctor may suggest you incorporate several heart-healthy lifestyle changes into your life, including: Keeping your blood pressure under control. Control of high blood pressure is important if you have mitral valve regurgitation. Eating a heart-healthy diet. But a healthy diet can help prevent other heart disease that can weaken the heart muscle. Eat foods that are low in saturated and trans fats, sugar, salt, and refined grains, such as white bread. Eat a variety of vegetables and fruits, whole grains, and proteins, such as lean meats, fish and nuts. Maintaining a healthy weight. Keep your weight within a range recommended by your doctor. If you have had a heart valve replaced, your doctor may recommend you take antibiotics before dental procedures to prevent an infection called infective endocarditis. Check with your doctor to find out if he or she recommends that you take antibiotics before dental procedures. Cutting back on alcohol. Heavy alcohol use can cause arrhythmias and can make your symptoms worse. Excessive alcohol use can also cause cardiomyopathy, a condition of weakened heart muscle that leads to mitral regurgitation. Ask your doctor about the effects of drinking alcohol. If you smoke, quit. Ask your doctor about resources to help you quit smoking. Joining a support group may be helpful. Getting regular physical activity. Seeing your doctor regularly. Establish a regular evaluation schedule with your cardiologist or primary care provider. Tell your doctor if you have any changes in your signs or symptoms. Pregnancy causes the heart to work harder. How a heart with mitral valve regurgitation tolerates this extra work depends on the degree of regurgitation and how well your heart pumps. Throughout your pregnancy and after delivery, your cardiologist and obstetrician should monitor you. Coping and support If you have mitral valve regurgitation, here are some steps that may help you cope: Take medications as prescribed. Take your medications as directed by your doctor. Having support from your family and friends can help you cope with your condition. Ask your doctor about support groups that may be helpful. Your doctor may give you recommendations about how much and what type of exercise is appropriate for you. Preparing for your appointment If you think you have mitral valve regurgitation, make an appointment to see your doctor. What you can do Be aware of pre-appointment restrictions. Write down your symptoms, including any that seem unrelated to mitral valve regurgitation. Write down key personal information, including a family history of heart disease, heart defects, genetic disorders, stroke, high blood pressure or diabetes, and any major stresses or recent life changes. Make a list of all medications, vitamins and supplements you take. Take a family member or friend along, if possible. Someone who accompanies you can help you remember information you receive. Be prepared to discuss your diet and exercise habits. Page 13