Mitral Valve Regurgitation

The patient may need heart surgery to repair or replace the valve for severe leakage or regurgitation. Left untreated, severe mitral valve regurgitation can cause heart failure or heart rhythm problems (arrhythmias).

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Symptoms

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Some people with mitral valve disease might not experience symptoms for many years. Signs and symptoms of mitral valve regurgitation, which depend on its severity and how quickly the condition develops, can include:

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• Abnormal heart sound (heart murmur) heard through a stethoscope

• Shortness of breath (dyspnea), especially when the patient has been very active or while lying down

• Fatigue

• Heart palpitations — sensations of a rapid, fluttering heartbeat

• Swollen feet or ankles

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Mitral valve regurgitation is often mild and progresses slowly. Patients may have no symptoms for many years and be unaware of this condition.

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The doctor might first suspect that the patient has mitral valve regurgitation upon detecting a heart murmur. Sometimes, however the problem develops quickly, and the patient may experience a sudden onset of severe symptoms.

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Causes

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Mitral valve regurgitation that is caused by problems related to the valve itself, is called primary mitral valve regurgitation. Diseases of the left ventricle can lead to secondary or functional mitral valve regurgitation.

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Possible causes of mitral valve regurgitation include:

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Mitral valve prolapse. In this condition, the mitral valve's leaflets bulge back into the left atrium during the heart's contraction. This common heart defect can prevent the mitral valve from closing tightly and lead to regurgitation.

Damaged tissue cords. Over time, the tissue cords that anchor the leaflets of the mitral valve to the heart wall may stretch or tear, especially in people with mitral valve prolapse. A tear can cause leakage through the mitral valve suddenly and may require repair by heart surgery. Trauma to the chest also can rupture the cords.

Rheumatic fever. Rheumatic fever — a complication of untreated strep throat — can damage the mitral valve, leading to mitral valve regurgitation early or later in life. Rheumatic fever is now rare in Greece, but it's still common in developing countries.

Endocarditis. The mitral valve may be damaged by an infection of the lining of the heart (endocarditis) that can involve heart valves.

Heart attack. A heart attack can damage the area of the heart muscle that supports the mitral valve, affecting the function of the valve. If the damage is extensive enough, a heart attack can cause sudden and severe mitral valve regurgitation.

Abnormality of the heart muscle (cardiomyopathy). Over time, certain conditions, such as high blood pressure, can cause your heart to work harder, gradually enlarging your heart's left ventricle. This can stretch the tissue around your mitral valve, which can lead to leakage.

Trauma. Experiencing trauma, such as in a car accident, can lead to mitral valve regurgitation.

Congenital heart defects. Some babies are born with defects in their hearts, including damaged heart valves.

Certain drugs. Prolonged use of certain medications can cause mitral valve regurgitation, such as those containing ergotamine that are used to treat migraines and other conditions.

Radiation therapy. In rare cases, radiation therapy for cancer that is focused on the chest area can lead to mitral valve regurgitation.

Atrial fibrillation. Atrial fibrillation is a common heart rhythm problem that can be a potential cause of mitral valve regurgitation.

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Risk factors

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Several factors can increase your risk of mitral valve regurgitation, including:

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• A history of mitral valve prolapse or mitral valve stenosis. However, having either condition doesn't necessarily mean someone will develop mitral valve regurgitation. A family history of valve disease also can increase risk.

• A heart attack. A heart attack can damage the heart, affecting the function of the mitral valve.

• Heart disease. Certain forms of heart disease, such as coronary artery disease, can lead to mitral valve regurgitation.

• Use of certain medications. People who take drugs containing ergotamine and similar medicines for migraines or who take cabergoline have an increased risk of mitral regurgitation. Similar problems were noted with the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold.

• Infections such as endocarditis or rheumatic fever. Infections or the inflammation can damage the mitral valve.

• Congenital heart disease. Some people are born with an abnormal mitral valve prone to regurgitation.

• Age. By middle age, many people have some mitral valve regurgitation caused by natural deterioration of the valve.

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Complications

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When it's mild, mitral valve regurgitation usually does not cause any problems. However, severe mitral valve regurgitation can lead to complications, including:

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• Heart failure. Heart failure results when the heart can't pump enough blood to meet the body's needs. Severe mitral valve regurgitation places an extra strain on the heart because, with blood pumping backward, there is less blood going forward with each heartbeat. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure. Also, high blood pressure in the lungs leading to fluid accumulation, strains the right side of the heart.

• Atrial fibrillation. The stretching and enlargement of the heart's left atrium may lead to this heart rhythm irregularity in which the upper chambers of the heart beat chaotically and rapidly. Atrial fibrillation can cause blood clots, which can break loose from the heart and travel to other parts of the body, causing serious problems, such as a stroke if a clot blocks a blood vessel of the brain.

• Pulmonary hypertension. If someone has long-term untreated or improperly treated mitral regurgitation, it can develop a type of high blood pressure in the lungs (pulmonary hypertension). A leaky mitral valve can increase pressure in the left atrium, which can eventually cause pulmonary hypertension. This can lead to failure of the right side of the heart.

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Diagnosis

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The doctor will ask about medical history and family history of heart disease and will also perform a physical exam that includes listening to the heart with a stethoscope. Mitral valve regurgitation usually produces a sound of blood leaking backward through the mitral valve (heart murmur).

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The doctor will then decide which tests are needed to make a diagnosis.

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Tests

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Common tests to diagnose mitral valve regurgitation include:

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• Echocardiogram. This test is commonly used to diagnose mitral valve regurgitation. In this test, sound waves directed at the heart from a wand like device (transducer) held on the chest produce video images of heart in motion. This test assesses the structure of the heart, the mitral valve and the blood flow through the heart. An echocardiogram helps doctor get a close look at the mitral valve and how well it's working. Doctors also may use a 3-D echocardiogram. Doctors may conduct another type of echocardiogram called a transesophageal echocardiogram. In this test, a small transducer attached to the end of a tube is inserted down the esophagus, which allows a closer look at the mitral valve than a regular echocardiogram does.

• Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on the skin record electrical impulses from the heart. An ECG can detect enlarged chambers of the heart and abnormal heart rhythms.

• Chest X-ray. This enables the doctor to determine whether the left atrium or the left ventricle is enlarged — possible indicators of mitral valve regurgitation — and the condition of the lungs.

• Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create detailed images of the heart. This test may be used to determine the severity of the condition and assess the size and function of the lower left heart chamber (left ventricle).

• Exercise tests or stress tests. Different exercise tests help measure the activity tolerance and monitor the heart's response to physical exertion. If unable to exercise, medications to mimic the effect of exercise on the heart may be used.

• Cardiac catheterization. This test isn't often used to diagnose mitral valve regurgitation. This invasive technique involves threading a thin tube (catheter) through a blood vessel of the arm or groin to an artery in to the heart and injecting dye through the catheter to make the artery visible on an X-ray. This provides a detailed picture of the heart arteries and how the heart functions. It can also measure the pressure inside the heart chambers.

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Treatment

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Mitral valve regurgitation treatment depends on how severe the condition is, if there are signs and symptoms, and if the condition is getting worse. The goal of treatment is to improve heart's function while minimizing symptoms and avoiding future complications.

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A doctor trained in heart disease (cardiologist) will provide the care. If someone has mitral valve regurgitation, should consider being treated at a medical center with a multidisciplinary team of doctors and medical staff trained and experienced in evaluating and treating heart valve disease. This team can work closely with the patient to determine the most appropriate treatment.

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Watchful waiting

Some people, especially those with mild regurgitation, might not need treatment. However, the condition may require monitoring by the doctor. Regular evaluations may be needed, with the frequency depending on the severity of the condition. The doctor may also recommend healthy lifestyle changes.

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Medications

The doctor may prescribe medication to treat symptoms, although medication can't treat mitral valve regurgitation.

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Surgery

Mitral valve may need to be repaired or replaced. The doctor may suggest mitral valve repair or replacement even if there are no symptoms, as this may prevent complications and improve outcome. If needed, surgery for another heart condition, the doctor may repair or replace the diseased mitral valve at the same time.

Mitral valve surgery is usually performed through incision of the chest. In some cases, doctors may conduct minimally invasive heart surgery, which involves the use of smaller incisions than those used in open-heart surgery.

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The doctor will discuss whether mitral valve repair or mitral valve replacement may be most appropriate for the condition. He or she may also evaluate to determine who is a candidate for minimally invasive heart surgery or open-heart surgery.

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Doctors often may recommend mitral valve repair, as it preserves the valve and may preserve heart function. However, if mitral valve repair isn't possible, doctors may need to perform mitral valve replacement with mechanic or biological valve.

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Biological or tissue valves degenerate over time, and often eventually need to be replaced. People with mechanical valves will need to take blood-thinning medications for life to prevent blood clots. The doctor will discuss with the patient the benefits and risks of each type of valve and which one will be more appropriate.