Surgical treatment is the best available treatment option, although percutaneous approaches have gained significant potential. The most common complications of surgical treatment are failure of repair, prosthetic valve stenosis, endocarditis, and mitral valve patient-prosthesis mismatch. The mitral valve apparatus consists of anterior and posterior leaflets, chordae tendineae, anterolateral and posteromedial papillary muscles, and mitral annulus.
Any aberrations of the mitral valve apparatus, due to mechanical, traumatic, infectious, degenerative, congenital, or metabolic causes, may lead to mitral regurgitation MR. Mild to moderate disease can be asymptomatic for many years; however, with progression of the disease, eccentric cardiac hypertrophy occurs, which leads to elongation of the myocardial fibres and increased left ventricular end-diastolic volume. Eventually, prolonged volume overload leads to left ventricular dysfunction and increased left ventricular end-systolic diameter.
Effective regurgitant orifice area EROA is considered a fundamental measure of lesion severity. An EROA of less than 0. An EROA of 0. Circulation ;;50a, 57a table 17, e; table 18, e There is a separate staging scheme for primary and secondary MR. Stage A at risk of primary MR comprises conditions characterized by mild mitral valve prolapse and mild valve thickening. The vena contracta is small — below 0.
No symptoms are present. Circulation ;;50a table 17, e Stage B progressive primary MR is anatomically characterized by moderate to severe mitral valve prolapse, rheumatic valve changes with leaflet restriction and prior infective endocarditis. There is mild LA enlargement, but no LV enlargement, and pulmonary pressure is normal. Stage C asymptomatic severe primary MR is defined by severe mitral valve prolapse with loss of coaptation or flail leaflet , rheumatic changes that restrict leaflet motion and cause loss of central coaptation, prior infective endocarditis or leaflet thickening with radiation heart disease.
The severe hemodynamics result in moderate or severe LA enlargement and LV enlargement and pulmonary hypertension may be present either at rest or during exercise. Stage D symptomatic severe primary MR is distinguished from Stage C primary MR by the presence of symptoms: decreased exercise tolerance and exertional dyspnea.
This stage is otherwise characterized by the same anatomic features, hemodynamic severity, and functional consequences as Stage C primary MR, except that pulmonary hypertension is typically present. Stage A at risk of secondary MR comprises cases where the mitral valve is anatomically normal in the presence of coronary artery disease CAD or cardiopathy. Valve hemodynamics are the same as in Stage A primary MR.
The primary myocardial pathology may result in LV dilation and dysfunction, with regional wall motion abnormalities. Circulation ;;57a table 18, e Stage B progressive secondary MR is characterized by regional wall motion abnormalities with mild tethering of mitral leaflets, or by annular dilation with mild loss of central coaptation.
Associated cardiac findings include LV dilation and dysfunction caused by the primary myocardial pathology. Associated cardiac findings are the same as in Stage B secondary MR. While symptoms attributable to coronary ischemia or heart failure may be present in Stage A through C secondary MR, they will abate in response to revascularization and appropriate medical therapy. Stage D symptomatic severe secondary MR is identical to Stage C secondary MR, except for the presence of symptoms that persist even after revascularization and optimal medical therapy, including symptoms of heart failure, decreased exercise tolerance and exertional dyspnea.
Due to the accuracy and non-invasive nature of echocardiography, cardiac catheterization is often not needed to diagnose or grade mitral regurgitation severity. Coronary angiography is indicated prior to surgical mitral valve repair or replacement to determine if concurrent coronary artery disease, possibly requiring concomitant bypass grafting, is present. Findings on catheterization include opacification of the left atrium during left ventriculography due to retrograde flow of contrast.
Apostolakis EE, et al. J Cardiothorac Surg. Appropriate treatment of mitral regurgitation requires an accurate diagnosis and should be based on the natural history of the underlying disease process.
Recent studies of percutaneous mitral valve repair have fundamentally altered the management of secondary mitral regurgitation based on the concept of proportionate and disproportionate mitral regurgitation. Circulation ;;55d-e e The data indicate that patients with disproportionate MR have larger effective regurgitant orifice areas and lower LV volumes benefit from percutaneous valve repair, whereas those with proportionate MR do not.
With primary mitral regurgitation, due to the potential complications of prosthetic valves, mitral valve repair is the surgical intervention of choice. When echocardiographic data indicate that mitral valve repair is feasible, a lower threshold for surgery may be considered.
Rheumatic mitral valve disease is less amenable to repair than degenerative mitral valve disease. Therefore, repair should be attempted only in patients with less advanced rheumatic mitral valve disease or those who are not candidates for a mechanical prosthesis because of anticoagulation management concerns.
Mitral valve replacement decreases symptoms of mitral regurgitation; however, data are lacking regarding a survival benefit compared with the natural history of chronic mitral regurgitation.
Conversely, mitral valve repair has been shown to reduce both symptoms and long-term mortality. Mitral valve regurgitation is often mild and progresses slowly. You may have no symptoms for many years and be unaware that you have this condition, and it might not progress.
Your doctor might first suspect you have mitral valve regurgitation upon detecting a heart murmur. Sometimes, however, the problem develops quickly, and you may experience a sudden onset of severe signs and symptoms. If your doctor hears a heart murmur when listening to your heart with a stethoscope, he or she may recommend that you visit a cardiologist and get an echocardiogram. If you develop symptoms that suggest mitral valve regurgitation or another problem with your heart, see your doctor right away.
Sometimes the first indications are actually those of mitral valve regurgitation's complications, including heart failure, a condition in which your heart can't pump enough blood to meet your body's needs.
A typical heart has two upper and two lower chambers. The upper chambers — the right and left atria — receive incoming blood. The lower chambers — the 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 for the tricuspid and mitral valves and exits for the pulmonary and aortic valves.
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.
Sometimes, the valves don't open or close properly, disrupting the blood flow through your heart to your body. The mitral valve separates the two chambers atrium and ventricle of the left side of the heart. In mitral valve prolapse, the leaflets of the mitral valve bulge prolapse into the left atrium like a parachute when the heart contracts. Sometimes mitral valve prolapse causes blood to leak back into the atrium from the ventricle, which is called mitral valve regurgitation.
In mitral valve regurgitation, the valve between the upper left heart chamber left atrium and the lower left heart chamber left ventricle doesn't close tightly, causing blood to leak backward into the left atrium regurgitation. 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. When it's mild, mitral valve regurgitation usually does not cause any problems.
Some studies look at exercise echocardiography to evaluate the response of the heart to exercise in severe MR. I am a year-old woman recently diagnosed with moderate MR.
Reading your post and blog responses has made me feel a lot better. Knowing that with moderate MR and normal heart function chambers and pressure good , exercise should not be a problem, makes me feel so much better.
I do have two questions. This happened long before I was diagnosed though, no idea how long I was undiagnosed, this was the first year she heard a murmur. Is this likely to be attributed to the MR or could this just be normal exertion due to the heat and hills?
I make a point of hydrating well and can run 3 to 4 hours on trails with no problem typically. Should dizziness be a concern? No pain, pressure, shortness of breath. Secondly, do you suggest that a person who exercises a lot and has moderate MR do a stress echo to see where they stand?
My GP suggested that, but I think before I do more tests I will meet with a cardiologist to ask some questions. Most times the answer would be that if the disease is moderate then just follow up in a year or two for a repeat study and in honesty in most cases that approach is adequate. Since you have intelligent questions on the issue, let me discuss the contemporary management in a situation such as yours patients that want to exercise to a high level that we would suggest in the setting of a specialist structural heart and valve center.
Is the regurgitation moderate or severe — Echocardiography is not an exact science. It is very dependent on who is performing the test and who is interpreting the test. In our valve clinic I personally for that reason oversee all studies done for valvular heart disease. In that case you should have an echocardiogram every year to ensure stability. Does the regurgitation get worse with exercise — If you were to have symptoms overtime you exercise then i would want to know whether the regurgitation is worsening with exertion or not.
Its important to recognize that mitral regurgitation is a dynamic condition. This is a specialist test however and needs to be done in expert hands by those used to performing this test for this reason. Say you developed symptoms at a high level of exercise, and also there was evidence of worsening regurgitation and other markers supporting that then i would certainly follow you more closely, likely at 6 months intervals. If however, no significant change occurs, that would certainly be reassuring.
In patients with confirmed severe mitral regurgitation exercise echocardiography can also be used to look for signs of subtle dysfunction of the heart muscle and make a case for earlier mitral valve repair.
Hello dr. I am 58 year old male. I have been exercising my complete life I do high intensity cardio 2 times week and regular exercise the other days and light weight lifting with no symptoms. I have trace regurgitation in my tricuspid, and mild regurgitation in the mitral valve. I have no symptoms! However my question is will this type of exercise make the regurgitation worse as I age?
Should I stop the high intensity work even though it is only 8 intervals of 30 seconds on and 90 seconds of rest. Thanks in advance. Mild mitral regurgitation should be considered an almost normal finding, no restrictions to activity whatsoever. Hi dr. What is the cause of the depressed function, has someone assessed the blood supply to the heart. The moderate mitral regurgitation in this setting does not require a valve operation.
Its important he is placed on good doses of the correct medications beta blocker, ACE inhibitor to strengthen the heart, and prevent enlargement, that may even improve the mitral regurgitation in this setting. They then sent me to a cardiologist where they gave me an echocardiogram. I received my results Tuesday that I have Mitral Valve Prolapse with moderate to severe regurgitation.
This of course is making me wonder if continuing with the knee surgery is a good idea at this time. Thank you in advance for anymore information that you can give to me. Firstly, the regurgitation in your case is not an emergency.
This should certainly not impede the issue of knee surgery. The next most important step is to ensure the correct diagnosis of severity of MR. The TEE is a good idea. I cant speak for all cardiologists, but as a valve specialist, i take the integrated assessment from the TEE, the TTE and possibly exercise testing to determine the severity and the impact of mitral regurgitation, so all the tests should support the same finding.
That should be what you are told when you get your opinion. Early surgery basically means operating on severe MR prior to the onset of symptoms. But early surgery should only be entertained if the valve can be repaired.
Sadly in the United States, a large proportion of people undergo replacement when they should have repair simply because they go to the wrong centers where the surgeons are not dedicated mitral valve surgeons. If there is clear heart enlargement, drop in heart function, atrial fibrillation, high lung pressures, or symptoms, then the need for surgery is more urgent, but still not emergent.
In your case, in the absence of those, there is no rush. But if you indeed have severe regurgitation that is clearly severe, it is reasonable to proceed with mitral valve repair at an expert center at a timing of your convenience. Thank you so much for your quick response! My knee surgery went well and I have an appointment with a cardiologist on the main land soon! Hi Doctor, I am 38 years old male and was diagnosed with mitral valve prolapse in Since then I was controlled regularly by a cardiologist, and my left ventricle was in the range of mm.
However, I changed country in and went to a new cardiologist after a year interval. New cardiologist told me that my left ventricle seems to be 62 mm. Which one to believe? In fact in my previous country, I was suspicious of my cardiologist and went for a second opinion from medical school. They also measured it cm. Two sources says but new one in a new country ireland says I have no symptoms and I am slim.
Can heart condition change so drastically within a year? Do they use different measurements? I spent several years conducting research in to just this issue and am a big fan of MRI, particularly in cases where the echocardiogram and other tests do not match up. The key is meticulous attention to detail. The MRI can provide an excellent assessment of remodeling and accurate delineation of ventricular size and shape.
Phase measurements through the valves can also assess degree of regurgitation. If there is ambiguity regarding severity of MR i. Practically MRI is not necessary in most cases, but is an excellent allied tool in more nuanced cases. Most of the time it feels like I have two heartbeats everytime I touch my chest. Most of the time I am having a hard time breathing and I also experienced a severe headache, and when that happens I go to the clinic to have a BP check and turns out I have low BP.
Are these things still normal? By the way, he told me to drink Propranolol Inderal 10mg for a month aftera my check up. The chest pain is not from the regurgitation. Some other posts linked at the end should also be useful to you. Thank you doctor, I will definitely inform you about the MRI results which will reveal which cardiologist measured it correctly.
Sir , i am sachin 25 year old report found mild mitral regurgitation on echo but dr. Im not sure why you were given Inderal, but it was not for the mild mitral regurgitation. Possibly for palpitations. The mild mitral regurgitation itself is nothing to worry about in isolation. Hi, I found out today that I have trivial mitral regurgitation, I am 44 yrs old, 84 kgs.
I have started to walk on a regular basis as a form of exercise. If I manage to lose some weight approx 10 kgs or a little more, obviously this will help my overall health.
But I would like to know can the mitral valve then stop leaking? You have trivial mitral regurgitation and you can consider this basically normal.
You can exercise and lose weight which may be beneficial to overall cardiac health however there is no evidence that will affect the mitral valve in any way. I have recently started walking as my form of exercise, I plan on losing 10 or more kilos, my question is, can the mitral valve stop leaking by losing weight?
Thickened mitral leaflets with mitral annular calcification and moderate mitral regurgitation. Its a little more complex than it seems. It depends whether you have primary or secondary mitral regurgitation. If it is primary then you need further testing such as TEE and heart catheterization to ensure it is not severe.
If it is severe and felt the cause of the left ventricular dysfunction then a conversation regarding surgery or other intervention can take place. The primary vs. Thank you for your quick response, let me just add the comments which was also included in the report:. Both atria are normal, the inter atrial septum is intact. There is mitral annular calcification with thickening of the mitral leaflets. E:A reversal and moderately severe regurgitation.
There is moderate pulmonary regurgitation with a pulmonary recoil spectral envelope. The other valves as well as the great vessels, appear normal with mild tricuspid regurgitation; estimated RVSP is TAPSE is 2. Next step would likely be a TEE to asses the mitral valve further and left or possibly stress testing and right heart catheterization.
Important to explain why the function is impaired. Mustafa last year i was confined at the hospital and doctor said i have mitral valve prolapse,acute gastritis and low potassium. You have trivial valve disease and nothing to worry about with regard to those.
There are significant risks that need to be understood very carefully. These should be discussed both with a cardiologist specializing in that area and an obstetrician. I am a very active half marathons and triathlons female. Sent me for an ECHO. Soonest appointment is 3 weeks from now. When I got my reports I read them and I learned I have Mitral valve mildly diffusely thickened, mild tricuspid regurgitation, prolapse mild trace aortic regurgitation. Trace to mild mitral regurgitation. Now I am scared that I am a walking time bomb.
Appointment with Cardiologist is not for awhile. Just a note on the dizzy aspect, the night before the race I had terrible diarrhea and felt pretty lousy, I thought I was just dehydrated so now I am all confused. Is my primary just being thorough or does my echo show I have big issues.
I am about to have my first panic attack. Never should have read those reports. Hope you can respond. Not sure if I should get to an ER right away. The echo sounds pretty normal to me. Certainly no underlying disease that would explain your symptoms. Possible it was due to feeling bad in general. You do not have issues as far as the echo is concerned so certainly no need for a panic attack.
Its reasonable to see a cardiologist for reassurance however its likely you will need no further testing and can resume your activity as normal, particularly if it is an isolated event. Thank you so much for your response. You really put me at ease and I feel so much better now. I see the cardiologist in a few weeks but I no longer feel like a walking time bomb. What a great service you are doing for people.
Thank you Caryl. I suffered chest pain,shortness of breath,palpitation etc…it is serious? Your mitral regurgitation is not significant and not cause for concern, it is not associated with heart attack. The actual terminology themselves are based on cut off values as described in the article.
Mild means it is a very low amount of leak, trivial means you can hardly see it. Hi Dr. I was diagnosed with Mitral Valve Prolapse with Mild Mitral Regurgitation 2 years ago back in October The 2D echo result shows that I have thickened and long anterior mitral valve leaflets with prolapsed; short posterior valve leaflets. The cardiologist prescribed propranolol to be taken as needed PRN for palpitations. I never had 2D Echo since then.
I know these symptoms were not caused by MVP itself. It depends on the degree of prolapse, in general thought mild mitral regurgitation is not likely to progress and is not a cause for concern. I am 85 y female w moderate stable mitral valve leakage. I have no shortness of breath. I take atenenol 25 mg 2x a day for BP. I walk 3 miles daily. What is my prognosis? Hi doc…im 28 yrs old and i have mild prolapse last yr in december..
Its not really seen in most people with mild prolapse, you may have dysautonomia. In terms of worrying, its more annoying than dangerous, although in some it can impair functioning due to the symptoms. Been told I got Moderate MR? Is there any cause of alarm? What known drugs can rectify this problem? I am 32 years. Moderate mitral regurgitation is not a cause for alarm although it should be followed clinically and occasionally through imaging.
In terms of drug, there is no recommended treatment specifically for the MR. It all depends on the mechanism. If the MR is primary, a disease of the valve then it is observed. If the MR is secondary and caused by heart muscle weakness then medication that concentrate on the heart function are preferred. Im guessing your MR is primary and you have no cause for concern, no specific treatment is recommended.
If you have no symptoms, no specific restrictions apply. The MR may never present an issue. Ahmed, I appreciate this health-management article. I am not 46 yrs old my surgeon was Dr. Wayne Isom same surgeon who did surgery on David Letterman only thing my surgery was back in Which I do get palpitations from time to time. During my hospital stay they did an echo cardiogram and my cardiologist told me I have residual RV enlargement and reduced systolic function with moderate MR.
Now I remember as a kid to an adult I would watch all my echos I got and always saw the Regurgitation but every cardiologist brushed it off as it is because you had the surgery and your heart is a little enlarged bc of the surgery.
I appreciate your thoughts on this. Your case is complex and i would need to see images etc to comment accurately. The RV enlargement is seen after yet repair and the key is to monitor it over time to ensure there is no residual pulmonary gradient etc. You may need right heart catheterization and such testing. They key for you is to be under the care of a congenital adult specialist who can monitor your situation closely.
I forgot to add I am taking Metoprolol 25mg 2x a day to control my heart rate, Eliquis 5mg 2x a day, Lisinopril 5mg 1x a day and Metformin.
No MVP. Trivial MR. Trace mitral regurgitation. Trace aortic regurgitation. Ahmed, Excellent coverage on this topic — thank you! I have been diagnosed with severe mitral value prolapse 5 years ago first diagnosed in my 20s with mild prolapse — now 63 years old and have been under the care of a cardiologist at a well-known NYC hospital since. We are taking the watch and wait approach. I really feel great and would not have any inkling that I have anything going on with my heart.
My question — even though i am in good health with no symptoms, should i be getting another opinion regarding the watch and wait approach? Thank you! A lot depends on the expertise available. Your tests are reassuring, contemporary management is showing a trend towards an earlier approach however.
Never restrictions. In great shape, feel great, great diet, work out every day. I have been deliberating for six months, even increased the exercise a bit, and have a second opinion scheduled in a couple of weeks. Am I being reasonable? It all depends on the expertise available. When i see patients, i take in to account that we are a mitral center of excellence, which means high experience, a high repair rate and good outcomes.
If a center has low volume and experience the recommendations are very different. In out center we adopt an early surgery approach whereby in reasonable candidates, once the MR is noted to be severe, we would operate, particularly if the valve is repairable. If you do have a large LV and severe MR, there is little to be gained from waiting. Its always important to make decisions on a case by case basis however, every case is different and many factors need taking in to account.
And even if it is severe with no symptoms , do I have much to lose by waiting perhaps another year when I can switch to a Medicare Supplement policy which would increase my access to doctors?
Hi George, in my opinion grading MR is somewhat an art form unless its clearly severe, i would initially recommend asking the cardiologist involved the features of the regurgitation that point towards severe from both a qualitative and a quantitative perspective.
These questions should be answered clearly. If not then its reasonable to ask further opinion. Normal LV size and no AF. My cardiologist will conduct a TEE to know more and probably refer me for early surgery if he finds a flail leaflet. Im not sure if he is still operating. I did promised i will post my experience as many forums as possible if i am cured, that i am doing now. I am a very active 61 year old woman. Triathlons, half marathons, swim daily, walk miles daily. This past October I got dizzy during a half marathon.
I was able to finish the race albeit mostly walking. I figured I was dehydrated. Followed up with my primary who referred me to a cardiologist. Because of the mitral valve history he ordered a stress echo, that resulted in no findings.
He said no heart concerns at all, 7 day monitor was normal, no family history, perfect cholesterol, blood pressure fine, never smoked. BUT I get chest pains, it has been years and never gave them a thought. All these tests have done a number on me. Every day I think I am having a heart attack.
I am driving myself and everyone around me crazy. I get chest pains, never severe, it is more discomfort, like more of an annoyance than severe pain, no other symptoms, I was checked 2 years ago for the same symptoms no changes.
My question for you is: should I be so scared of having a heart attack if there are no symptoms at all, I am full of anxiety and have been my whole life, the pains last minutes or hours but again this has been going on years, no breathing issues, sweating, I feel absolutely fine. Can you put me at ease or should I get another cardio work up? Look at it this way, you are remarkably active, and fit, you have atypical symptoms, you have a structurally pretty normal heart, you live a good lifestyle, you had a stress test and a cardiology evaluation that was normal.
You are the definition of low risk. Mustafa Ahmed, I will appreciate your opinion. Your presentation and blog answers are very informative.. Thanks 67 yrs. Male- active retired in med profession but consult full time , 5.
Meds; — Topro, lost 10 lbs.?? Recently developed unexplained GERD. And now- PAH. Will start with ace inhibitor this week. Should I wait and watch. I stopped walk exercise- Should I do routinely for now. Left ventricle: Systolic function is normal. Mitral valve: Moderate, late systolicprolapse, involving the anterior leaflet. There is moderate to severe regurgitation. Left atrium: The atrium is markedly dilated. Tricuspid valve: There is moderate regurgitation.
Pulmonary arteries: Systolic pressure is markedly increased, estimated to be 75rnrn Hg. Wall thickness is normal. There is no hypertrophy. Systolic function is normal. The study is not technically sufficient to allow evaluation of LV diastolic function. Doppler: There is no evidence for stenosis.
Walking Regadenoson Protocol 0. A few questions. Have you been assessed for conventional surgery? In terms of technical suitability, i would need to see the images myself to comment.
Interesting that the pulmonary artery pressure is so high, i think a right heart catheterization in addition to the left heart cath would confirm that and also assess for there v wave of mitral regurgitation. AV Peak Velocity 1. E to A Ratio 0. There is no left ventricular hypertrophy.
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