Acute mitral regurgitation in adults
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
Patients with acute mitral regurgitation (MR) are often gravely ill with significant hemodynamic abnormalities that require urgent medical and usually surgical treatment .
The pathophysiology, clinical features, and management of acute MR will be reviewed here. The changes that occur in chronic MR are discussed separately. (See "Pathophysiology of chronic mitral regurgitation" and "Clinical manifestations and diagnosis of chronic mitral regurgitation".)
Although there are many causes of acute mitral regurgitation (MR), many of which can, under other circumstances, also cause chronic MR, there are only three basic mechanisms of acute native valve MR (figure 1):
●Ruptured mitral chordae tendineae (flail leaflet) due to myxomatous disease (mitral valve prolapse) , infective endocarditis, or trauma , rheumatic heart disease (acute rheumatic fever  or chronic rheumatic mitral valve disease), or spontaneous rupture [5,6]. This complication has also been reported with a mechanical circulatory support device due to device displacement .
●Papillary muscle rupture due to acute myocardial infarction or trauma or papillary muscle displacement due to myocardial infarction or ischemia. (See "Mechanical complications of acute myocardial infarction" and "Management and prognosis of chronic secondary mitral regurgitation".)
- Stout KK, Verrier ED. Acute valvular regurgitation. Circulation 2009; 119:3232.
- Grenadier E, Alpan G, Keidar S, Palant A. The prevalence of ruptured chordae tendineae in the mitral valve prolapse syndrome. Am Heart J 1983; 105:603.
- Grinberg AR, Finkielman JD, Piñeiro D, et al. Rupture of mitral chorda tendinea following blunt chest trauma. Clin Cardiol 1998; 21:300.
- Anderson Y, Wilson N, Nicholson R, Finucane K. Fulminant mitral regurgitation due to ruptured chordae tendinae in acute rheumatic fever. J Paediatr Child Health 2008; 44:134.
- Kaymaz C, Ozdemir N, Ozkan M. Differentiating clinical and echocardiographic characteristics of chordal rupture detected in patients with rheumatic mitral valve disease and floppy mitral valve: impact of the infective endocarditis on chordal rupture. Eur J Echocardiogr 2005; 6:117.
- Gabbay U, Yosefy C. The underlying causes of chordae tendinae rupture: a systematic review. Int J Cardiol 2010; 143:113.
- Elhussein TA, Hutchison SJ. Acute mitral regurgitation: unforeseen new complication of the Impella LP 5.0 ventricular assist device and review of literature. Heart Lung Circ 2014; 23:e100.
- Bouabdallaoui N, Wang Z, Lecomte M, et al. Acute mitral regurgitation in Takotsubo cardiomyopathy. Eur Heart J Acute Cardiovasc Care 2015; 4:197.
- Gaasch WH, Meyer TE. Left ventricular response to mitral regurgitation: implications for management. Circulation 2008; 118:2298.
- Ogunbayo GO, Thambiaiyah S, Ojo AO, Obaji A. 'Atypical pneumonia': acute mitral regurgitation presenting with unilateral infiltrate. Am J Med 2015; 128:e5.
- Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 2005; 111:295.
- Tcheng JE, Jackman JD Jr, Nelson CL, et al. Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction. Ann Intern Med 1992; 117:18.
- Lehmann KG, Francis CK, Dodge HT. Mitral regurgitation in early myocardial infarction. Incidence, clinical detection, and prognostic implications. TIMI Study Group. Ann Intern Med 1992; 117:10.
- Barzilai B, Gessler C Jr, Pérez JE, et al. Significance of Doppler-detected mitral regurgitation in acute myocardial infarction. Am J Cardiol 1988; 61:220.
- Stone GW, Griffin B, Shah PK, et al. Prevalence of unsuspected mitral regurgitation and left ventricular diastolic dysfunction in patients with coronary artery disease and acute pulmonary edema associated with normal or depressed left ventricular systolic function. Am J Cardiol 1991; 67:37.
- Goldman AP, Glover MU, Mick W, et al. Role of echocardiography/Doppler in cardiogenic shock: silent mitral regurgitation. Ann Thorac Surg 1991; 52:296.
- Woolley K, Stark P. Pulmonary parenchymal manifestations of mitral valve disease. Radiographics 1999; 19:965.
- Attias D, Mansencal N, Auvert B, et al. Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema. Circulation 2010; 122:1109.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- Piérard LA, Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 2004; 351:1627.
- Chatterjee K, Parmley WW, Swan HJ, et al. Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus. Circulation 1973; 48:684.
- Harshaw CW, Grossman W, Munro AB, McLaurin LP. Reduced systemic vascular resistance as therapy for severe mitral regurgitation of valvular origin. Ann Intern Med 1975; 83:312.
- Sasayama S, Takahashi M, Osakada G, et al. Dynamic geometry of the left atrium and left ventricle in acute mitral regurgitation. Circulation 1979; 60:177.
- Rankin JS, Hickey MS, Smith LR, et al. Ischemic mitral regurgitation. Circulation 1989; 79:I116.
- Tepe NA, Edmunds LH Jr. Operation for acute postinfarction mitral insufficiency and cardiogenic shock. J Thorac Cardiovasc Surg 1985; 89:525.
- Hickey MS, Smith LR, Muhlbaier LH, et al. Current prognosis of ischemic mitral regurgitation. Implications for future management. Circulation 1988; 78:I51.
- Replogle RL, Campbell CD. Surgery for mitral regurgitation associated with ischemic heart disease. Results and strategies. Circulation 1989; 79:I122.
- Lorusso R, Gelsomino S, De Cicco G, et al. Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study. Eur J Cardiothorac Surg 2008; 33:573.
- Roberts WC, Braunwald E, Morrow AG. Acute severe mitral regurgitation secondary to ruptured chordae tendineae: clinical, hemodynamic, and pathologic considerations. Circulation 1966; 33:58.
- Oliveira DB, Dawkins KD, Kay PH, Paneth M. Chordal rupture. II: comparison between repair and replacement. Br Heart J 1983; 50:318.
- Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation 2015; 132:1435.
- Habib G, Hoen B, Tornos P, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009; 30:2369.
- Lalani T, Cabell CH, Benjamin DK, et al. Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias. Circulation 2010; 121:1005.
- Mihaljevic T, Paul S, Leacche M, et al. Tailored surgical therapy for acute native mitral valve endocarditis. J Heart Valve Dis 2004; 13:210.
- Iung B, Rousseau-Paziaud J, Cormier B, et al. Contemporary results of mitral valve repair for infective endocarditis. J Am Coll Cardiol 2004; 43:386.
- Feringa HH, Shaw LJ, Poldermans D, et al. Mitral valve repair and replacement in endocarditis: a systematic review of literature. Ann Thorac Surg 2007; 83:564.
- Iung B. Management of ischaemic mitral regurgitation. Heart 2003; 89:459.
- Le Feuvre C, Metzger JP, Lachurie ML, et al. Treatment of severe mitral regurgitation caused by ischemic papillary muscle dysfunction: indications for coronary angioplasty. Am Heart J 1992; 123:860.
- Lehmann KG, Francis CK, Sheehan FH, Dodge HT. Effect of thrombolysis on acute mitral regurgitation during evolving myocardial infarction. Experience from the Thrombolysis in Myocardial Infarction (TIMI) Trial. J Am Coll Cardiol 1993; 22:714.
- Wei JY, Hutchins GM, Bulkley BH. Papillary muscle rupture in fatal acute myocardial infarction: a potentially treatable form of cardiogenic shock. Ann Intern Med 1979; 90:149.
- Manning WJ, Waksmonski CA, Boyle NG. Papillary muscle rupture complicating inferior myocardial infarction: identification with transesophageal echocardiography. Am Heart J 1995; 129:191.
- DiSesa VJ, Cohn LH, Collins JJ Jr, et al. Determinants of operative survival following combined mitral valve replacement and coronary revascularization. Ann Thorac Surg 1982; 34:482.
- Russo A, Suri RM, Grigioni F, et al. Clinical outcome after surgical correction of mitral regurgitation due to papillary muscle rupture. Circulation 2008; 118:1528.
- Chevalier P, Burri H, Fahrat F, et al. Perioperative outcome and long-term survival of surgery for acute post-infarction mitral regurgitation. Eur J Cardiothorac Surg 2004; 26:330.
- Estévez-Loureiro R, Arzamendi D, Freixa X, et al. Percutaneous Mitral Valve Repair for Acute Mitral Regurgitation After an Acute Myocardial Infarction. J Am Coll Cardiol 2015; 66:91.
- CLINICAL MANIFESTATIONS
- Physical examination
- Cardiac auscultation
- - Silent MR
- Chest radiograph
- - Exercise echocardiography
- Cardiac catheterization
- Medical stabilization
- - Chordal rupture
- - Infective endocarditis
- - Ischemic MR
- Transcatheter mitral valve repair
- SUMMARY AND RECOMMENDATIONS