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

Management of chronic primary mitral regurgitation

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

INTRODUCTION

Management of patients with chronic primary mitral regurgitation (MR) requires an understanding of the pathophysiology and natural history of the disease (table 1) and the efficacy and timing of treatment, particularly mitral valve repair and replacement. While our knowledge of these areas is incomplete, a rational plan for management based upon the available evidence is presented here [1,2].

Primary MR is caused by a primary abnormality of one or more components of the valve apparatus (leaflets, chordae tendineae, papillary muscles, annulus) in contrast to secondary MR, which is caused by another cardiac disease (such as coronary heart disease or a cardiomyopathy) (table 2). Identification of the cause and type (primary or secondary) of MR is required for appropriate management of MR as well as any associated conditions.

The pathophysiology, natural history, diagnosis, and evaluation of chronic mitral regurgitation, and the management of chronic secondary MR are presented elsewhere. (See "Pathophysiology of chronic mitral regurgitation" and "Natural history of chronic mitral regurgitation caused by mitral valve prolapse and flail mitral leaflet" and "Clinical manifestations and diagnosis of chronic mitral regurgitation" and "Management and prognosis of chronic secondary mitral regurgitation".)

STAGING

Staging of primary mitral regurgitation (MR) is based upon symptoms, valve anatomy, valve hemodynamics (severity of MR), and hemodynamic consequences of MR as reflected by left atrial size, left ventricular size and function, and pulmonary artery pressure (table 3) [1]:

In stage A, patients are at risk of MR (or have mild MR). There are mild mitral valve abnormalities (mild mitral valve prolapse or mild valve thickening and leaflet restriction) with no or mild MR (small central jet <20 percent of left atrium on color Doppler with vena contracta <0.3 cm). The left atrial and left ventricular sizes are normal and there are no symptoms.

                                           

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 15 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. 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.
  2. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
  3. Gaasch WH, Meyer TE. Left ventricular response to mitral regurgitation: implications for management. Circulation 2008; 118:2298.
  4. Leung DY, Griffin BP, Stewart WJ, et al. Left ventricular function after valve repair for chronic mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol 1996; 28:1198.
  5. Magne J, Lancellotti P, Piérard LA. Exercise-induced changes in degenerative mitral regurgitation. J Am Coll Cardiol 2010; 56:300.
  6. Magne J, Lancellotti P, Piérard LA. Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. Circulation 2010; 122:33.
  7. Donal E, Mascle S, Brunet A, et al. Prediction of left ventricular ejection fraction 6 months after surgical correction of organic mitral regurgitation: the value of exercise echocardiography and deformation imaging. Eur Heart J Cardiovasc Imaging 2012; 13:922.
  8. Bergler-Klein J, Gyöngyösi M, Maurer G. The role of biomarkers in valvular heart disease: focus on natriuretic peptides. Can J Cardiol 2014; 30:1027.
  9. Detaint D, Messika-Zeitoun D, Avierinos JF, et al. B-type natriuretic peptide in organic mitral regurgitation: determinants and impact on outcome. Circulation 2005; 111:2391.
  10. Magne J, Mahjoub H, Pierard LA, et al. Prognostic importance of brain natriuretic peptide and left ventricular longitudinal function in asymptomatic degenerative mitral regurgitation. Heart 2012; 98:584.
  11. Hwang IC, Kim YJ, Kim KH, et al. Prognostic value of B-type natriuretic peptide in patients with chronic mitral regurgitation undergoing surgery: mid-term follow-up results. Eur J Cardiothorac Surg 2013; 43:e1.
  12. Perreas K, Samanidis G, Dimitriou S, et al. NT-proBNP in the mitral valve surgery. Crit Pathw Cardiol 2014; 13:55.
  13. Wisenbaugh T, Sinovich V, Dullabh A, Sareli P. Six month pilot study of captopril for mildly symptomatic, severe isolated mitral and isolated aortic regurgitation. J Heart Valve Dis 1994; 3:197.
  14. Marcotte F, Honos GN, Walling AD, et al. Effect of angiotensin-converting enzyme inhibitor therapy in mitral regurgitation with normal left ventricular function. Can J Cardiol 1997; 13:479.
  15. Ahmed MI, Aban I, Lloyd SG, et al. A randomized controlled phase IIb trial of beta(1)-receptor blockade for chronic degenerative mitral regurgitation. J Am Coll Cardiol 2012; 60:833.
  16. Varadarajan P, Joshi N, Appel D, et al. Effect of Beta-blocker therapy on survival in patients with severe mitral regurgitation and normal left ventricular ejection fraction. Am J Cardiol 2008; 102:611.
  17. Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. J Am Coll Cardiol 1996; 28:1083.
  18. Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 115 published online April 19, 2007. www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1 (Accessed on May 04, 2007).
  19. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol 2005; 45:1334.
  20. Bonow RO, Nishimura RA, Thompson PD, Udelson JE. Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 5: Valvular Heart Disease: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2015; 66:2385.
  21. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
  22. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005; 352:875.
  23. Kang DH, Kim JH, Rim JH, et al. Comparison of early surgery versus conventional treatment in asymptomatic severe mitral regurgitation. Circulation 2009; 119:797.
  24. Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet 2009; 373:1382.
  25. Tribouilloy CM, Enriquez-Sarano M, Schaff HV, et al. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation 1999; 99:400.
  26. David TE, Ivanov J, Armstrong S, Rakowski H. Late outcomes of mitral valve repair for floppy valves: Implications for asymptomatic patients. J Thorac Cardiovasc Surg 2003; 125:1143.
  27. Grigioni F, Enriquez-Sarano M, Ling LH, et al. Sudden death in mitral regurgitation due to flail leaflet. J Am Coll Cardiol 1999; 34:2078.
  28. Samad Z, Kaul P, Shaw LK, et al. Impact of early surgery on survival of patients with severe mitral regurgitation. Heart 2011; 97:221.
  29. Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 2006; 113:2238.
  30. Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA 2013; 310:609.
  31. Montant P, Chenot F, Robert A, et al. Long-term survival in asymptomatic patients with severe degenerative mitral regurgitation: a propensity score-based comparison between an early surgical strategy and a conservative treatment approach. J Thorac Cardiovasc Surg 2009; 138:1339.
  32. Enriquez-Sarano M, Suri RM, Clavel MA, et al. Is there an outcome penalty linked to guideline-based indications for valvular surgery? Early and long-term analysis of patients with organic mitral regurgitation. J Thorac Cardiovasc Surg 2015; 150:50.
  33. Goldstone AB, Patrick WL, Cohen JE, et al. Early surgical intervention or watchful waiting for the management of asymptomatic mitral regurgitation: a systematic review and meta-analysis. Ann Cardiothorac Surg 2015; 4:220.
  34. Gillinov AM, Mihaljevic T, Blackstone EH, et al. Should patients with severe degenerative mitral regurgitation delay surgery until symptoms develop? Ann Thorac Surg 2010; 90:481.
  35. Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 1994; 90:830.
  36. Zile MR, Gaasch WH, Carroll JD, Levine HJ. Chronic mitral regurgitation: predictive value of preoperative echocardiographic indexes of left ventricular function and wall stress. J Am Coll Cardiol 1984; 3:235.
  37. Tribouilloy C, Rusinaru D, Szymanski C, et al. Predicting left ventricular dysfunction after valve repair for mitral regurgitation due to leaflet prolapse: additive value of left ventricular end-systolic dimension to ejection fraction. Eur J Echocardiogr 2011; 12:702.
  38. Song JM, Kang SH, Lee EJ, et al. Echocardiographic predictors of left ventricular function and clinical outcomes after successful mitral valve repair: conventional two-dimensional versus speckle-tracking parameters. Ann Thorac Surg 2011; 91:1816.
  39. Suri RM, Schaff HV, Dearani JA, et al. Recovery of left ventricular function after surgical correction of mitral regurgitation caused by leaflet prolapse. J Thorac Cardiovasc Surg 2009; 137:1071.
  40. Crawford MH, Souchek J, Oprian CA, et al. Determinants of survival and left ventricular performance after mitral valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease. Circulation 1990; 81:1173.
  41. 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.
  42. Betriu A, Chaitman BR, Almazan A. Preoperative determinants of return to sinus rhythm after valve replacement. In: Cardiac Bioprosthesis, Cohn LH, Gallucci V (Eds), York Medical, New York 1982. p.184.
  43. Flugelman MY, Hasin Y, Katznelson N, et al. Restoration and maintenance of sinus rhythm after mitral valve surgery for mitral stenosis. Am J Cardiol 1984; 54:617.
  44. Barbieri A, Bursi F, Grigioni F, et al. Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: a multicenter long-term international study. Eur Heart J 2011; 32:751.
  45. Murashita T, Okada Y, Kanemitsu H, et al. The impact of preoperative and postoperative pulmonary hypertension on long-term surgical outcome after mitral valve repair for degenerative mitral regurgitation. Ann Thorac Cardiovasc Surg 2015; 21:53.
  46. Gillinov AM, Blackstone EH, Cosgrove DM 3rd, et al. Mitral valve repair with aortic valve replacement is superior to double valve replacement. J Thorac Cardiovasc Surg 2003; 125:1372.
  47. Le Tourneau T, Messika-Zeitoun D, Russo A, et al. Impact of left atrial volume on clinical outcome in organic mitral regurgitation. J Am Coll Cardiol 2010; 56:570.
  48. Messika-Zeitoun D, Johnson BD, Nkomo V, et al. Cardiopulmonary exercise testing determination of functional capacity in mitral regurgitation: physiologic and outcome implications. J Am Coll Cardiol 2006; 47:2521.
  49. Dillon J, Yakub MA, Kong PK, et al. Comparative long-term results of mitral valve repair in adults with chronic rheumatic disease and degenerative disease: is repair for "burnt-out" rheumatic disease still inferior to repair for degenerative disease in the current era? J Thorac Cardiovasc Surg 2015; 149:771.
Topic Outline

GRAPHICS