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Pathophysiology of chronic mitral regurgitation

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

INTRODUCTION

Chronic mitral regurgitation (MR) is a relatively common valvular disorder that can progress to ventricular decompensation and the need for mitral valve surgery. The pathophysiology and phases of chronic MR will be reviewed here. The etiology, clinical features, natural history, and overview of management are discussed separately. (See "Clinical manifestations and diagnosis of chronic mitral regurgitation" and "Natural history of chronic mitral regurgitation caused by mitral valve prolapse and flail mitral leaflet" and "Management of chronic primary mitral regurgitation".)

PATHOPHYSIOLOGY

Causes and mechanisms — Mitral regurgitation (MR) may be due to a primary abnormality (often referred to as organic MR) of one or more components of the valve apparatus (leaflets, chordae tendineae, papillary muscles, and/or annulus) or may be secondary (often referred to as functional MR) to left ventricular (LV) dysfunction (such as coronary heart disease or a cardiomyopathy) (table 1). In the developed world, the most common etiologies of MR are degenerative disease with mitral valve prolapse (a primary cause) and coronary heart disease (a secondary cause).

Primary MR — Several disease processes cause abnormalities of the mitral valve complex leading to primary MR.

Degenerative mitral valve disease (mitral valve prolapse, partial flail, and flail leaflet) includes a range of disorders 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. In mitral valve prolapse, excessive mitral leaflet tissues leads to folding and hooding effecting one or more segments of one or both leaflets. Chordae are elongated and may rupture and the annulus is typically dilated and frequently disjuncted from its normal myocardial support. The alterations yield insufficient apposition of the rough zones of the mitral leaflets so they no longer support each other during systole and fall into the left atrium. (See "Definition and diagnosis of mitral valve prolapse", section on 'Pathology'.)

Among patients with acute rheumatic carditis, the intensity and time course of the inflammatory process may impact the course of mitral valve disease. Severe inflammation of the chordal structures and mitral valve leaflets can lead to isolated MR, seen predominantly in children and young adults. Moderate chordal and leaflet inflammation, which may be exacerbated by repeated acute rheumatic carditis, may lead to mixed MR and mitral stenosis. Chronic chordal and leaflet inflammation may be exacerbated by repeated acute rheumatic carditis which may lead to mitral stenosis (algorithm 1). (See "Natural history, screening, and management of rheumatic heart disease", section on 'Natural history'.)

                  

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Literature review current through: Nov 2016. | This topic last updated: Wed Dec 30 00:00:00 GMT+00:00 2015.
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References
Top
  1. 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.
  2. 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.
  3. Pinero A, Marcos-Alberca P, Fortes J. Cabergoline-related severe restrictive mitral regurgitation. N Engl J Med 2005; 353:1976.
  4. Aronow WS, Kronzon I. Correlation of prevalence and severity of mitral regurgitation and mitral stenosis determined by Doppler echocardiography with physical signs of mitral regurgitation and mitral stenosis in 100 patients aged 62 to 100 years with mitral anular calcium. Am J Cardiol 1987; 60:1189.
  5. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 2001; 122:1125.
  6. Miller DC. Ischemic mitral regurgitation redux--to repair or to replace? J Thorac Cardiovasc Surg 2001; 122:1059.
  7. Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112:745.
  8. Heuser RR, Maddoux GL, Goss JE, et al. Coronary angioplasty for acute mitral regurgitation due to myocardial infarction. A nonsurgical treatment preserving mitral valve integrity. Ann Intern Med 1987; 107:852.
  9. Shawl FA, Forman MB, Punja S, Goldbaum TS. Emergent coronary angioplasty in the treatment of acute ischemic mitral regurgitation: long-term results in five cases. J Am Coll Cardiol 1989; 14:986.
  10. Weinstein JM, Kidman G, Ilia R. Collateral-dependent ischemic mitral regurgitation. J Invasive Cardiol 2014; 26:E27.
  11. Hemayat S, Shafiee A, Oraii S, et al. Development of mitral and tricuspid regurgitation in right ventricular apex versus right ventricular outflow tract pacing. J Interv Card Electrophysiol 2014; 40:81.
  12. Fanari Z, Hammami S, Hammami MB, et al. The effects of right ventricular apical pacing with transvenous pacemaker and implantable cardioverter defibrillator on mitral and tricuspid regurgitation. J Electrocardiol 2015; 48:791.
  13. Uemura T, Otsuji Y, Nakashiki K, et al. Papillary muscle dysfunction attenuates ischemic mitral regurgitation in patients with localized basal inferior left ventricular remodeling: insights from tissue Doppler strain imaging. J Am Coll Cardiol 2005; 46:113.
  14. 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.
  15. Izumi S, Miyatake K, Beppu S, et al. Mechanism of mitral regurgitation in patients with myocardial infarction: a study using real-time two-dimensional Doppler flow imaging and echocardiography. Circulation 1987; 76:777.
  16. Magne J, Pibarot P. Left ventricular systolic function in ischemic mitral regurgitation: time to look beyond ejection fraction. J Am Soc Echocardiogr 2013; 26:1130.
  17. Chaput M, Handschumacher MD, Tournoux F, et al. Mitral leaflet adaptation to ventricular remodeling: occurrence and adequacy in patients with functional mitral regurgitation. Circulation 2008; 118:845.
  18. Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation 1991; 84:2167.
  19. Hung J, Guerrero JL, Handschumacher MD, et al. Reverse ventricular remodeling reduces ischemic mitral regurgitation: echo-guided device application in the beating heart. Circulation 2002; 106:2594.
  20. Tenenbaum A, Leor J, Motro M, et al. Improved posterobasal segment function after thrombolysis is associated with decreased incidence of significant mitral regurgitation in a first inferior myocardial infarction. J Am Coll Cardiol 1995; 25:1558.
  21. 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.
  22. 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.
  23. Gaasch, WH, Levine, HJ, Zile, MR. Chronic aortic and mitral regurgitation: Mechanical consequences of the lesion and the results of surgical correction. In: The Ventricle, Gaasch, WH, Levin, HJ (Eds), Martinus Nijhoff Publishing, Boston 1985. p.237.
  24. Carabello BA. Mitral valve disease. Curr Probl Cardiol 1993; 18:423.
  25. Gaasch WH, Meyer TE. Left ventricular response to mitral regurgitation: implications for management. Circulation 2008; 118:2298.
  26. Ross J Jr, Sonnenblick EH, Taylor RR, et al. Diastolic geometry and sarcomere lengths in the chronically dilated canine left ventricle. Circ Res 1971; 28:49.
  27. Gaasch WH, Zile MR. Left ventricular function after surgical correction of chronic mitral regurgitation. Eur Heart J 1991; 12 Suppl B:48.
  28. Shah PM, Adelman AG, Wigle ED, et al. The natural (and unnatural) history of hypertrophic obstructive cardiomyopathy. Circ Res 1974; 35:suppl II:179.
  29. Zile MR, Gaasch WH, Levine HJ. Left ventricular stress-dimension-shortening relations before and after correction of chronic aortic and mitral regurgitation. Am J Cardiol 1985; 56:99.
  30. Corin WJ, Monrad ES, Murakami T, et al. The relationship of afterload to ejection performance in chronic mitral regurgitation. Circulation 1987; 76:59.
  31. Goldfine H, Aurigemma GP, Zile MR, Gaasch WH. Left ventricular length-force-shortening relations before and after surgical correction of chronic mitral regurgitation. J Am Coll Cardiol 1998; 31:180.
  32. Corin WJ, Sütsch G, Murakami T, et al. Left ventricular function in chronic mitral regurgitation: preoperative and postoperative comparison. J Am Coll Cardiol 1995; 25:113.
  33. Rozich JD, Carabello BA, Usher BW, et al. Mitral valve replacement with and without chordal preservation in patients with chronic mitral regurgitation. Mechanisms for differences in postoperative ejection performance. Circulation 1992; 86:1718.
  34. Lee EM, Shapiro LM, Wells FC. Importance of subvalvular preservation and early operation in mitral valve surgery. Circulation 1996; 94:2117.
  35. Schuler G, Peterson KL, Johnson A, et al. Temporal response of left ventricular performance to mitral valve surgery. Circulation 1979; 59:1218.
  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. Wisenbaugh T, Skudicky D, Sareli P. Prediction of outcome after valve replacement for rheumatic mitral regurgitation in the era of chordal preservation. Circulation 1994; 89:191.
  38. Borow KM, Green LH, Mann T, et al. End-systolic volume as a predictor of postoperative left ventricular performance in volume overload from valvular regurgitation. Am J Med 1980; 68:655.
  39. Carabello BA, Nolan SP, McGuire LB. Assessment of preoperative left ventricular function in patients with mitral regurgitation: value of the end-systolic wall stress-end-systolic volume ratio. Circulation 1981; 64:1212.
  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. Ross J Jr. Afterload mismatch in aortic and mitral valve disease: implications for surgical therapy. J Am Coll Cardiol 1985; 5:811.
  42. 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.
  43. Gaasch WH, John RM, Aurigemma GP. Managing asymptomatic patients with chronic mitral regurgitation. Chest 1995; 108:842.
  44. Zuppiroli A, Rinaldi M, Kramer-Fox R, et al. Natural history of mitral valve prolapse. Am J Cardiol 1995; 75:1028.