UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Clinical manifestations and diagnosis of chronic mitral regurgitation

Author
Catherine M Otto, MD
Section Editors
William H Gaasch, MD
Warren J Manning, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Mitral regurgitation (MR) is a common valvular disorder that can arise from abnormalities of any part of the mitral valve apparatus. These include the valve leaflets, annulus, chordae tendineae, and papillary muscles (table 1 and figure 1). The left atrium and ventricle are also integrally involved with mitral valve function.

The etiology and clinical manifestations of chronic MR will be reviewed here. Issues related to acute MR, pathophysiology of chronic MR and management of chronic MR are discussed separately. (See "Acute mitral regurgitation in adults" and "Pathophysiology of chronic mitral regurgitation" and "Management of chronic primary mitral regurgitation" and "Management and prognosis of chronic secondary mitral regurgitation".)

ETIOLOGY

Mitral regurgitation (MR) may be due to a primary abnormality (often referred to organic MR) of one or more components of the valve apparatus (leaflets, chordae tendineae, papillary muscles, and/or annulus) or may be secondary (previously referred to as functional MR) to another cardiac disease (such as coronary heart disease or a cardiomyopathy) (table 1). (See "Pathophysiology of chronic mitral regurgitation", section on 'Causes and mechanisms'.)

The causes of primary (also known as organic) MR include:

Degenerative mitral valve disease (including mitral valve prolapse) is the most common cause of primary MR in developed countries. It includes a spectrum of disease ranging from myxomatous mitral valve disease (also known as myxomatous degeneration, with redundancy of anterior and posterior mitral leaflets and the chordae), seen primarily in younger populations, and fibroelastic deficiency disease, seen primarily in older populations. It is not clear if these are two distinct disease processes or manifestations of a single disease. (See "Definition and diagnosis of mitral valve prolapse" and "Nonarrhythmic complications of mitral valve prolapse".)

                      

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Fri Jan 29 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Marijon E, Ou P, Celermajer DS, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med 2007; 357:470.
  2. Marcus RH, Sareli P, Pocock WA, Barlow JB. The spectrum of severe rheumatic mitral valve disease in a developing country. Correlations among clinical presentation, surgical pathologic findings, and hemodynamic sequelae. Ann Intern Med 1994; 120:177.
  3. Chockalingam A, Gnanavelu G, Elangovan S, Chockalingam V. Clinical spectrum of chronic rheumatic heart disease in India. J Heart Valve Dis 2003; 12:577.
  4. Redfield MM, Nicholson WJ, Edwards WD, Tajik AJ. Valve disease associated with ergot alkaloid use: echocardiographic and pathologic correlations. Ann Intern Med 1992; 117:50.
  5. Van Camp G, Flamez A, Cosyns B, et al. Treatment of Parkinson's disease with pergolide and relation to restrictive valvular heart disease. Lancet 2004; 363:1179.
  6. Pinero A, Marcos-Alberca P, Fortes J. Cabergoline-related severe restrictive mitral regurgitation. N Engl J Med 2005; 353:1976.
  7. Jones EC, Devereux RB, Roman MJ, et al. Prevalence and correlates of mitral regurgitation in a population-based sample (the Strong Heart Study). Am J Cardiol 2001; 87:298.
  8. Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999; 83:897.
  9. Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999; 341:1.
  10. Flack JM, Kvasnicka JH, Gardin JM, et al. Anthropometric and physiologic correlates of mitral valve prolapse in a biethnic cohort of young adults: the CARDIA study. Am Heart J 1999; 138:486.
  11. Freed LA, Benjamin EJ, Levy D, et al. Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study. J Am Coll Cardiol 2002; 40:1298.
  12. 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.
  13. 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.
  14. Barzilai B, Davis VG, Stone PH, Jaffe AS. Prognostic significance of mitral regurgitation in acute myocardial infarction. The MILIS Study Group. Am J Cardiol 1990; 65:1169.
  15. Pellizzon GG, Grines CL, Cox DA, et al. Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. J Am Coll Cardiol 2004; 43:1368.
  16. 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.
  17. Perez de Isla L, Zamorano J, Quezada M, et al. Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome. Eur Heart J 2006; 27:2655.
  18. Aronson D, Goldsher N, Zukermann R, et al. Ischemic mitral regurgitation and risk of heart failure after myocardial infarction. Arch Intern Med 2006; 166:2362.
  19. Trichon BH, O'Connor CM. Secondary mitral and tricuspid regurgitation accompanying left ventricular systolic dysfunction: is it important, and how is it treated? Am Heart J 2002; 144:373.
  20. Strauss RH, Stevenson LW, Dadourian BA, Child JS. Predictability of mitral regurgitation detected by Doppler echocardiography in patients referred for cardiac transplantation. Am J Cardiol 1987; 59:892.
  21. Koelling TM, Aaronson KD, Cody RJ, et al. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 2002; 144:524.
  22. Stolfo D, Merlo M, Pinamonti B, et al. Early improvement of functional mitral regurgitation in patients with idiopathic dilated cardiomyopathy. Am J Cardiol 2015; 115:1137.
  23. Cirit M, Ozkahya M, Cinar CS, et al. Disappearance of mitral and tricuspid regurgitation in haemodialysis patients after ultrafiltration. Nephrol Dial Transplant 1998; 13:389.
  24. 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.
  25. Piérard LA, Lancellotti P. The role of ischemic mitral regurgitation in the pathogenesis of acute pulmonary edema. N Engl J Med 2004; 351:1627.
  26. Yamano T, Nakatani S, Kanzaki H, et al. Exercise-induced changes of functional mitral regurgitation in asymptomatic or mildly symptomatic patients with idiopathic dilated cardiomyopathy. Am J Cardiol 2008; 102:481.
  27. Reed D, Abbott RD, Smucker ML, Kaul S. Prediction of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation. The importance of left atrial size. Circulation 1991; 84:23.
  28. Desjardins VA, Enriquez-Sarano M, Tajik AJ, et al. Intensity of murmurs correlates with severity of valvular regurgitation. Am J Med 1996; 100:149.
  29. Uretsky S, Gillam L, Lang R, et al. Discordance between echocardiography and MRI in the assessment of mitral regurgitation severity: a prospective multicenter trial. J Am Coll Cardiol 2015; 65:1078.
  30. Grayburn PA, Weissman NJ, Zamorano JL. Quantitation of mitral regurgitation. Circulation 2012; 126:2005.
  31. Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112:745.
  32. Tabata T, Thomas JD, Klein AL. Pulmonary venous flow by doppler echocardiography: revisited 12 years later. J Am Coll Cardiol 2003; 41:1243.
  33. Hayakawa M, Inoh T, Kawanishi H, et al. [Two-dimensional echocardiographic findings of patients with papillary muscle dysfunction]. J Cardiogr 1982; 12:137.
  34. Godley RW, Wann LS, Rogers EW, et al. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation 1981; 63:565.
  35. Yiu SF, Enriquez-Sarano M, Tribouilloy C, et al. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation 2000; 102:1400.
  36. Otto CM. Clinical practice. Evaluation and management of chronic mitral regurgitation. N Engl J Med 2001; 345:740.
  37. Levine RA. Dynamic mitral regurgitation--more than meets the eye. N Engl J Med 2004; 351:1681.
  38. Enriquez-Sarano M, Freeman WK, Tribouilloy CM, et al. Functional anatomy of mitral regurgitation: accuracy and outcome implications of transesophageal echocardiography. J Am Coll Cardiol 1999; 34:1129.
  39. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
  40. Otto CM, Salerno CT. Timing of surgery in asymptomatic mitral regurgitation. N Engl J Med 2005; 352:928.
  41. Topilsky Y, Michelena H, Bichara V, et al. Mitral valve prolapse with mid-late systolic mitral regurgitation: pitfalls of evaluation and clinical outcome compared with holosystolic regurgitation. Circulation 2012; 125:1643.
  42. Kon MW, Myerson SG, Moat NE, Pennell DJ. Quantification of regurgitant fraction in mitral regurgitation by cardiovascular magnetic resonance: comparison of techniques. J Heart Valve Dis 2004; 13:600.
  43. Buchner S, Debl K, Poschenrieder F, et al. Cardiovascular magnetic resonance for direct assessment of anatomic regurgitant orifice in mitral regurgitation. Circ Cardiovasc Imaging 2008; 1:148.
  44. Cawley PJ, Maki JH, Otto CM. Cardiovascular magnetic resonance imaging for valvular heart disease: technique and validation. Circulation 2009; 119:468.
  45. Lancellotti P, Lebrun F, Piérard LA. Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol 2003; 42:1921.
  46. Lancellotti P, Troisfontaines P, Toussaint AC, Pierard LA. Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction. Circulation 2003; 108:1713.
Topic Outline

GRAPHICS