Vasodilator therapy in chronic mitral regurgitation
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
Patients with severe mitral regurgitation (MR), especially those with heart failure, may experience a dramatic hemodynamic improvement during intravenous vasodilator therapy . Based in part upon these observations, it would seem reasonable to consider the use of oral vasodilators in selected patients with chronic MR.
Candidates for such therapy could include certain patients who are not candidates for surgery, particularly those with end-stage decompensated MR, and those with compensated MR in whom surgery is not yet indicated. In the latter group, the goal of vasodilator therapy might be to reduce the rate of progression of the hemodynamic burden and, therefore, to delay the onset of symptoms and the need for corrective surgery.
An overview of the management of chronic MR is presented separately. (See "Management of chronic primary mitral regurgitation".)
DETERMINANTS OF REGURGITANT VOLUME
The volume of mitral regurgitant volume (MRV) is determined hydraulically by two factors:
●The duration (D) and magnitude of the systolic pressure gradient across the valve; the latter is determined by the difference between the left ventricular and left atrial systolic pressures (LVP and LAP). It can be especially important to consider the duration factor in the evaluation of patients with mitral valve prolapse .
Subscribers log in hereLiterature review current through: Jun 2017. | This topic last updated: Apr 13, 2016.References
- Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. J Am Coll Cardiol 1996; 28:1083.
- 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.
- Gaasch WH, Aurigemma GP. Inhibition of the renin-angiotensin system and the left ventricular adaptation to mitral regurgitation. J Am Coll Cardiol 2002; 39:1380.
- Dujardin KS, Enriquez-Sarano M, Bailey KR, et al. Effect of losartan on degree of mitral regurgitation quantified by echocardiography. Am J Cardiol 2001; 87:570.
- Rosario LB, Stevenson LW, Solomon SD, et al. The mechanism of decrease in dynamic mitral regurgitation during heart failure treatment: importance of reduction in the regurgitant orifice size. J Am Coll Cardiol 1998; 32:1819.
- Wisenbaugh T, Spann JF, Carabello BA. Differences in myocardial performance and load between patients with similar amounts of chronic aortic versus chronic mitral regurgitation. J Am Coll Cardiol 1984; 3:916.
- Corin WJ, Monrad ES, Murakami T, et al. The relationship of afterload to ejection performance in chronic mitral regurgitation. Circulation 1987; 76:59.
- 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.
- 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.
- Goodman DJ, Rossen RM, Holloway EL, et al. Effect of nitroprusside on left ventricular dynamics in mitral regurgitation. Circulation 1974; 50:1025.
- 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, Ohyagi A, Lee JD, et al. Effect of the vasodilator therapy in regurgitant valvular disease. Jpn Circ J 1982; 46:433.
- Greenberg BH, Massie BM, Brundage BH, et al. Beneficial effects of hydralazine in severe mitral regurgitation. Circulation 1978; 58:273.
- Greenberg BH, DeMots H, Murphy E, Rahimtoola SH. Arterial dilators in mitral regurgitation: effects on rest and exercise hemodynamics and long-term clinical follow-up. Circulation 1982; 65:181.
- Wisenbaugh T, Essop R, Rothlisberger C, Sareli P. Effects of a single oral dose of captopril on left ventricular performance in severe mitral regurgitation. Am J Cardiol 1992; 69:348.
- Röthlisberger C, Sareli P, Wisenbaugh T. Comparison of single dose nifedipine and captopril for chronic severe mitral regurgitation. Am J Cardiol 1994; 73:978.
- Schön HR, Schröter G, Blömer H, Schömig A. Beneficial effects of a single dose of quinapril on left ventricular performance in chronic mitral regurgitation. Am J Cardiol 1994; 73:785.
- Sniderman AD, Marpole DG, Palmer WH, Fallen EL. Response of the left ventricle to nitroglycerin in patients with and without mitral regurgitation. Br Heart J 1974; 36:357.
- Elkayam U, Roth A, Kumar A, et al. Hemodynamic and volumetric effects of venodilation with nitroglycerin in chronic mitral regurgitation. Am J Cardiol 1987; 60:1106.
- Jeang MK, Petrovich LJ, Adyanthaya AV, Alexander J. Effects of isosorbide dinitrate on rheumatic and non-rheumatic mitral regurgitation. Tex Heart Inst J 1986; 13:453.
- Levine AB, Muller C, Levine TB. Effects of high-dose lisinopril-isosorbide dinitrate on severe mitral regurgitation and heart failure remodeling. Am J Cardiol 1998; 82:1299.
- Schön HR, Schröter G, Barthel P, Schömig A. Quinapril therapy in patients with chronic mitral regurgitation. J Heart Valve Dis 1994; 3:303.
- 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.
- 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.
- Iung B, Gohlke-Bärwolf C, Tornos P, et al. Recommendations on the management of the asymptomatic patient with valvular heart disease. Eur Heart J 2002; 23:1253.
- Perry GJ, Wei CC, Hankes GH, et al. Angiotensin II receptor blockade does not improve left ventricular function and remodeling in subacute mitral regurgitation in the dog. J Am Coll Cardiol 2002; 39:1374.
- Borer JS, Sharma A. Drug Therapy for Heart Valve Diseases. Circulation 2015; 132:1038.