Functional mitral regurgitation

INTRODUCTION

In patients with functional or secondary mitral regurgitation (MR), the papillary muscles, chordae, and valve leaflets are normal. There are two major causes of this problem: ischemia and any cause of dilated left ventricle. In these settings, MR may result from one or both of the following [1]:

  • Annular enlargement secondary to left ventricular dilatation (figure 1)
  • Papillary muscle displacement due to left ventricular remodeling, which results in tethering and excess tenting of the leaflet [2] (see "Cardiac remodeling: Basic aspects")

A rare cause of functional MR is standard right ventricular (RV) pacing. RV pacing simulates the effects of left bundle branch block, with dyssynchronous contraction of the left and right ventricles. This dyssynchrony may alter the timing and function of papillary muscles and mitral valve apparatus, resulting in MR that can be severe, even in the setting of otherwise normal cardiac structure and function [3]. Dyssynchrony from either RV pacing or intrinsic conduction disease can be improved with biventricular (BiV) pacing. (See 'Cardiac resynchronization therapy' below and "Cardiac resynchronization therapy in heart failure: Indications".)

Functional MR in association with systolic heart failure will be reviewed here. There is clear overlap between functional and ischemic MR, since the reports of functional MR due to heart failure include patients with ischemic cardiomyopathy. The clinical features and management of ischemic MR, including MR in association with myocardial infarction, are discussed separately. (See "Ischemic mitral regurgitation".)

PATHOPHYSIOLOGY

Echocardiographic studies of functional mitral regurgitation (MR) have shown that regurgitant flow varies during systole: there is an early systolic peak, a midsystolic decrease, and a late, smaller late systolic peak [4,5]. In one series, the respective values for regurgitant flow at these three time periods were 144, 13, and 62 mL/sec [5]. These variations occur in association with parallel changes in regurgitant orifice area and are more closely associated with changes in transmitral pressure, which drives the leaflets toward closure, than mitral annular area [4].

         

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Literature review current through: Nov 2014. | This topic last updated: Sep 17, 2012.
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References
Top
  1. 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.
  2. 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.
  3. Barold SS, Ovsyshcher IE. Pacemaker-induced mitral regurgitation. Pacing Clin Electrophysiol 2005; 28:357.
  4. Hung J, Otsuji Y, Handschumacher MD, et al. Mechanism of dynamic regurgitant orifice area variation in functional mitral regurgitation: physiologic insights from the proximal flow convergence technique. J Am Coll Cardiol 1999; 33:538.
  5. Fukuda S, Grimm R, Song JM, et al. Electrical conduction disturbance effects on dynamic changes of functional mitral regurgitation. J Am Coll Cardiol 2005; 46:2270.
  6. Blondheim DS, Jacobs LE, Kotler MN, et al. Dilated cardiomyopathy with mitral regurgitation: decreased survival despite a low frequency of left ventricular thrombus. Am Heart J 1991; 122:763.
  7. 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.
  8. 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.
  9. 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.
  10. Conti JB, Mills RM Jr. Mitral regurgitation and death while awaiting cardiac transplantation. Am J Cardiol 1993; 71:617.
  11. Dini FL, Conti U, Fontanive P, et al. Right ventricular dysfunction is a major predictor of outcome in patients with moderate to severe mitral regurgitation and left ventricular dysfunction. Am Heart J 2007; 154:172.
  12. Mehra MR, Griffith BP. Is mitral regurgitation a viable treatment target in heart failure? The plot just thickened. J Am Coll Cardiol 2005; 45:388.
  13. Seneviratne B, Moore GA, West PD. Effect of captopril on functional mitral regurgitation in dilated heart failure: a randomised double blind placebo controlled trial. Br Heart J 1994; 72:63.
  14. Keren G, Pardes A, Eschar Y, et al. One-year clinical and echocardiographic follow-up of patients with congestive cardiomyopathy treated with captopril compared to placebo. Isr J Med Sci 1994; 30:90.
  15. Capomolla S, Febo O, Gnemmi M, et al. Beta-blockade therapy in chronic heart failure: diastolic function and mitral regurgitation improvement by carvedilol. Am Heart J 2000; 139:596.
  16. Lowes BD, Gill EA, Abraham WT, et al. Effects of carvedilol on left ventricular mass, chamber geometry, and mitral regurgitation in chronic heart failure. Am J Cardiol 1999; 83:1201.
  17. Groenning BA, Nilsson JC, Sondergaard L, et al. Antiremodeling effects on the left ventricle during beta-blockade with metoprolol in the treatment of chronic heart failure. J Am Coll Cardiol 2000; 36:2072.
  18. Calafiore AM, Gallina S, Di Mauro M, et al. Mitral valve procedure in dilated cardiomyopathy: repair or replacement? Ann Thorac Surg 2001; 71:1146.
  19. Carabello BA. Is it ever too late to operate on the patient with valvular heart disease? J Am Coll Cardiol 2004; 44:376.
  20. Bach DS, Bolling SF. Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy. Am Heart J 1995; 129:1165.
  21. Bolling SF, Pagani FD, Deeb GM, Bach DS. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg 1998; 115:381.
  22. Chen FY, Adams DH, Aranki SF, et al. Mitral valve repair in cardiomyopathy. Circulation 1998; 98:II124.
  23. Wu AH, Aaronson KD, Bolling SF, et al. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J Am Coll Cardiol 2005; 45:381.
  24. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391.
  25. Heart Failure Society of America, Lindenfeld J, Albert NM, et al. HFSA 2010 Comprehensive Heart Failure Practice Guideline. J Card Fail 2010; 16:e1.
  26. Martin-Rendon E, Hale SJ, Ryan D, et al. Transcriptional profiling of human cord blood CD133+ and cultured bone marrow mesenchymal stem cells in response to hypoxia. Stem Cells 2007; 25:1003.
  27. Breithardt OA, Sinha AM, Schwammenthal E, et al. Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. J Am Coll Cardiol 2003; 41:765.
  28. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352:1539.
  29. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346:1845.
  30. van Bommel RJ, Marsan NA, Delgado V, et al. Cardiac resynchronization therapy as a therapeutic option in patients with moderate-severe functional mitral regurgitation and high operative risk. Circulation 2011; 124:912.
  31. Brandt RR, Reiner C, Arnold R, et al. Contractile response and mitral regurgitation after temporary interruption of long-term cardiac resynchronization therapy. Eur Heart J 2006; 27:187.