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Key Features

  • Mitral regurgitation results from

    • Displacement of papillary muscles (dilated cardiomyopathy)

    • Excessive length of chordae or myxomatous degeneration of leaflets (mitral prolapse)

    • Noncontraction of annulus (annular calcification)

    • Scarring (rheumatic fever, calcific invasion)

    • Infection (endocarditis)

  • Places a volume load on heart (increased preload), but reduces afterload, resulting in enlarged left ventricle (LV) and initial increase in ejection fraction (EF)

  • Over time, myocardial contractile function is reduced and EF drops

Clinical Findings

  • Pansystolic murmur at the apex, radiating into the axilla in most patients; murmur does not change in intensity after a premature beat, since the LV to left atrial (LA) gradient is unaffected

  • Often associated with an S3

  • Hyperdynamic LV impulse

  • Brisk carotid upstroke

  • May be asymptomatic for many years (or life)

  • When regurgitation develops acutely, left atrial pressure rises abruptly, leading to pulmonary edema if severe

  • When regurgitation progresses more slowly, exertional dyspnea and fatigue worsen gradually over many years

  • Chronic LA and LV enlargement and may result in subsequent atrial fibrillation and LV dysfunction

  • Systemic embolization occurs but is relatively unusual compared with other conditions causing atrial fibrillation

Diagnosis

  • ECG: LA abnormality or atrial fibrillation and LV hypertrophy

  • Chest radiograph: LA and LV enlargement

  • Doppler echocardiography

    • Confirms the diagnosis, etiology and estimates severity by a variety of methods

    • Used for measuring LV function and LV end-systolic and diastolic sizes

    • Should be done at least yearly in patients with severe mitral regurgitation (stage C1) but preserved LV dimensions

  • Transesophageal echocardiography

    • May reveal the cause and better identify candidates for valvular repair

    • Important in endocarditis

  • Coronary angiography is often indicated to determine the presence of coronary artery disease before valve surgery in all men over age 40 years and menopausal women with risk factors

  • Exercise hemodynamics with either Doppler echocardiography or cardiac catheterization may be useful when the symptoms do not fit the anatomic severity of mitral regurgitation

  • B-type natriuretic peptide (BNP or pro-NT-BNP) is useful in the early identification of LV dysfunction in the presence of mitral regurgitation

Treatment

  • Chronic regurgitation usually requires surgery when symptoms develop or in asymptomatic patients when the LV end-systolic dimension (LVESD) is > 4.0 cm or EF < 60%

  • The 2017 update of the valvular guidelines has added a IIa indication for mitral valve surgery when the LVEF is > 60% and the LVESD is still < 4.0 cm

    • The guidelines suggest that mitral valve replacement should be done if serial imaging reveals a progressive increase in the LVESD or a decrease in the EF

    • This latter was based on information that LV function is more likely to return to normal when the LVEF was > 64% and the LVESD was < 3.7 cm

  • Calculated regurgitant orifice areas > 40 mm2 by echocardiogram are considered severe

  • Surgical valve repair

    • Preferred in mitral prolapse and in some with endocarditis

    • Essentially all patients who undergo valve repair also get ...

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