Mitral valve regurgitation

Mitral valve regurgitation is a type of heart valve disease in which the valve between the left heart chambers doesn't close completely, allowing blood to leak backward across the valve. It is the most common type of heart valve disease (valvular heart disease). If the leakage is severe, not enough blood will move through the heart or to the rest of the body. As a result, mitral valve regurgitation can make you feel very tired (fatigued) or short of breath.

Other names for mitral valve regurgitation are:

• Mitral regurgitation (MR)
• Mitral insufficiency
• Mitral incompetence

Treatment of mitral valve regurgitation may include regular monitoring, medications or surgery. Some people with mitral regurgitation don't need treatment, especially when the regurgitation is mild.

Severe mitral valve regurgitation often requires a catheter procedure or heart surgery to repair or replace the mitral valve. Without proper treatment, severe mitral valve regurgitation can cause heart rhythm problems (arrhythmias) or heart failure.

Symptoms

Mitral valve regurgitation is often mild and progresses slowly. Some people with mitral valve regurgitation might not have symptoms for many years.

But sometimes, mitral valve regurgitation develops quickly. This condition, called acute mitral valve regurgitation, causes sudden signs and symptoms.

Fatigue is a common but nonspecific symptom of mitral valve regurgitation. Other signs and symptoms of mitral valve regurgitation include:

• Sound of blood flow across the valve (heart murmur)
• Irregular heartbeat (arrhythmia)
• Shortness of breath (dyspnea), especially when lying down
• Sensation of a rapid, pounding or fluttering heartbeat (palpitations)
• Swollen feet or ankles (edema)

When to see a doctor

If you develop symptoms that suggest mitral valve regurgitation or another problem with your heart, see your health care provider right away.

If you have a heart murmur, you may be referred to a doctor that specializes in heart diseases (cardiologist).

Causes

To understand the causes of mitral valve disease, it may be helpful to know how the heart works.

The mitral valve is one of four valves in the heart that keep blood flowing in the right direction. Each valve has flaps (leaflets) that open and close once during each heartbeat. If a valve doesn't open or close properly, blood flow through the heart to the body can be reduced.

In mitral valve regurgitation, the valve flaps don't close tightly. Blood leaks backward when the valve is closed, making it harder for the heart to work properly.

If mitral valve regurgitation is due to problems with the mitral valve, the condition is called primary mitral valve regurgitation.

If a problem or disease affecting other areas of the heart cause a leaky mitral valve, the condition is called functional or secondary mitral regurgitation.

Possible causes of mitral valve regurgitation include:

• Mitral valve prolapse. In this condition, the mitral valve's flaps bulge back into the left upper heart chamber (atrium) when the heart squeezes (contracts). This common heart problem can prevent the mitral valve from closing tightly and cause blood to flow backward.
• Rheumatic fever. Rheumatic fever is a complication of untreated strep throat. Rheumatic fever can damage the mitral valve, leading to mitral valve regurgitation early or later in life. If rheumatic fever causes mitral valve disease, the condition is called rheumatic mitral valve disease. Rheumatic fever is rare in the United States.
• Heart attack. A heart attack can damage the area of the heart muscle that supports the mitral valve. If heart attack damage is very extensive, the event can cause sudden and severe mitral valve regurgitation. A leaky mitral valve caused by a heart attack is called ischemic mitral regurgitation.
• Heart problem present at birth (congenital heart defect). Some people are born with heart structure problems, including damaged heart valves.
• Thickening of the heart muscle (cardiomyopathy). Cardiomyopathy makes it harder for the heart to pump blood to the rest of the body. The condition can affect mitral valve function and may lead to regurgitation. Types of cardiomyopathy linked to mitral valve regurgitation include dilated cardiomyopathy and hypertrophic cardiomyopathy.
• Damaged tissue cords. Over time, the pieces of tissue that hold the flaps of the mitral valve to the heart wall may stretch or tear, especially in people with mitral valve prolapse. A tear can cause blood leakage through the mitral valve suddenly and may require mitral valve repair surgery. A chest injury also can cause rupture of the cords.
• Endocarditis. The mitral valve may be damaged by an infection of the lining of the heart (endocarditis) that can involve heart valves.
• Radiation therapy. Rarely, radiation therapy for cancer that is focused on the chest area can lead to mitral valve regurgitation.

Risk factors

Several things can increase the risk of mitral valve regurgitation, including:

• Certain infections that affect the heart
• Heart attack
• Heart problems present at birth (congenital heart defect)
• History of other heart valve diseases, including mitral valve prolapse and mitral valve stenosis
• Older age
• Radiation to the chest

Complications

Mitral valve regurgitation complications often depend on the severity of disease. Mild mitral valve regurgitation usually does not cause any problems.

As mitral valve regurgitation gets worse, the heart must work harder to pump blood to the body. The strain on the heart can cause the left lower chamber to widen. The heart muscle may become weak.

Potential complications of severe mitral valve regurgitation include:

• Irregular and often rapid heart rate (atrial fibrillation). Increased size of the upper left heart chamber (atrium) caused by mitral valve regurgitation may trigger this common heart rhythm disorder. Atrial fibrillation has been linked to an increased risk of blood clots and stroke.
• High blood pressure in the lungs (pulmonary hypertension). Long-term untreated or improperly treated mitral regurgitation can increase pressure in the blood vessels in the lungs. As pressure rises, fluid builds up in the lungs.
• Congestive heart failure. In severe mitral valve regurgitation, the heart has to work harder to pump enough blood to the body. The extra effort causes the left lower heart chamber (ventricle) to get bigger. Untreated, the heart muscle becomes weak. This can cause heart failure.

Diagnosis

To diagnose mitral valve regurgitation, a health care provider will usually do a physical exam and ask questions about your symptoms and medical history, including whether you have mitral valve prolapse. The provider will typically listen to your heart with a stethoscope. A heart murmur, also called a holosystolic murmur, may be heard. The mitral valve heart murmur is the sound of blood leaking backward through the valve.

Tests may be done to confirm a diagnosis of mitral valve regurgitation or to check for other conditions that can cause similar signs and symptoms.

Tests

Common tests to diagnose mitral valve regurgitation include:

• Echocardiogram. Sound waves are used to create pictures of the heart in motion. An echocardiogram shows the structure of the mitral valve and blood flow in the heart. A standard echocardiogram, also called a transthoracic echocardiogram (TTE), can confirm a diagnosis of mitral valve regurgitation and determine its severity. Echocardiography can also help in the diagnosis of congenital mitral valve disease, rheumatic mitral valve disease and other heart valve conditions.

  Sometimes, a transesophageal echocardiogram (TTE) may be done to get a closer look at the mitral valve. In this type of echocardiogram, a small transducer attached to the end of a tube is inserted down the tube leading from the mouth to the stomach (esophagus).

• Electrocardiogram (ECG). Wires (electrodes) attached to pads on the skin measure electrical signals from the heart. An ECG can detect irregular heart rhythms (arrhythmias) related to mitral valve disease.
• Chest X-ray. A chest X-ray shows the condition of the heart and lungs. This quick and easy test can help diagnose an enlarged heart or fluid in the lungs.
• Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create detailed images of the heart. Cardiac MRI may help provide more details about the severity of mitral valve regurgitation and the size and function of the lower left heart chamber (left ventricle).
• Exercise tests or stress tests. These tests often involve walking on a treadmill or riding a stationary bike while the heart is monitored. Exercise tests show how the heart responds to physical activity and whether mitral valve regurgitation symptoms occur during exercise. If you can't exercise, you might be given medication that mimics the effect of exercise on the heart.
• Cardiac catheterization. This test isn't often used to diagnose mitral valve disease, but it can be helpful if other tests haven't diagnosed the condition. A health care provider threads a thin tube (catheter) through a blood vessel in the arm or groin to an artery in the heart and injects dye through the catheter. This makes the arteries in the heart chambers show up more clearly on an X-ray.

Staging

After testing confirms a diagnosis of mitral or other heart valve disease, your health care provider may tell you the stage of disease. Staging helps determine the most appropriate treatment.

The stage of heart valve disease depends on many things, including symptoms, disease severity, the structure of the valve or valves, and blood flow through the heart and lungs.

Heart valve disease is staged into four basic groups:

• Stage A: At risk. Risk factors for heart valve disease are present.
• Stage B: Progressive. Valve disease is mild or moderate. There are no heart valve symptoms.
• Stage C: Asymptomatic severe. There are no heart valve symptoms, but the valve disease is severe.
• Stage D: Symptomatic severe. Heart valve disease is severe and is causing symptoms.

Outlook

How well a person does after being diagnosed with mitral valve regurgitation varies. The outlook (prognosis) for mitral valve regurgitation depends on:

• The cause of the mitral valve disease
• The stage of heart valve disease
• The severity of the leakage (regurgitation)
• How long the condition has been present (duration)

About one in 10 people with chronic mitral valve regurgitation due to prolapse needs surgery to repair or replace the valve.

Treatment

The goals of mitral valve regurgitation treatment are to improve heart function while reducing signs and symptoms and avoiding future complications. Some people, especially those with mild regurgitation, might not need treatment. Your health care provider will consider your symptoms and stage of regurgitation, among other things, when discussing treatment options with you.

Treatment of mitral valve regurgitation may include:

• Healthy lifestyle changes
• Regular monitoring by a health care provider
• Medications to treat symptoms and prevent complications, such as blood clots
• Surgery to repair or replace the mitral valve

A doctor trained in heart disease (cardiologist) typically provides care for people with mitral valve regurgitation. If you have mitral valve regurgitation, consider being treated at a medical center with a multidisciplinary team of health care providers trained and experienced in evaluating and treating heart valve disease.

Medications

Medications may be needed to reduce mitral valve regurgitation symptoms and to prevent complications of heart valve disease.

Types of medications that may be prescribed for mitral valve regurgitation include:

• Diuretics. Sometimes called water pills, this type of medication reduces or prevents fluid buildup in the lungs and other parts of the body.
• Blood thinners (anticoagulants). If you have atrial fibrillation due to mitral valve disease, such as mitral valve regurgitation, your health care provider may recommend blood-thinning drugs to prevent blood clots. Atrial fibrillation increases the risk of blood clots and strokes.
• Blood pressure medications. High blood pressure (hypertension) makes mitral valve regurgitation worse. If you have mitral valve regurgitation and hypertension, your health care provider may prescribe medication to lower blood pressure.

Surgery or other procedures

A diseased or damaged mitral valve might eventually need to be repaired or replaced, even if you don't have symptoms. Surgery for mitral valve disease includes mitral valve repair and mitral valve replacement. Your health care provider can discuss the risks and benefits of each type of heart valve with you to determine which valve may be best for you.

If you need surgery for another heart condition, a surgeon might perform mitral valve repair or replacement at the same time as that other surgery.

Mitral valve surgery is usually done through a cut (incision) in the chest. Surgeons at some medical centers sometimes use robot-assisted heart surgery, a minimally invasive procedure in which robotic arms are used to do the surgery.

Mitral valve repair

Mitral valve repair saves the existing valve and may preserve heart function. Whenever possible, mitral valve repair is recommended before considering valve replacement. People who have mitral valve repair for mitral regurgitation at an experienced medical center generally have good outcomes.

During mitral valve repair surgery, the surgeon might:

• Patch holes in a heart valve
• Reconnect the valve flaps
• Remove excess tissue from the valve so that the flaps can close tightly
• Repair the structure of the mitral valve by replacing cords that support it
• Separate valve leaflets that have fused

Other mitral valve repair procedures include:

• Annuloplasty. A surgeon tightens or reinforces the ring around the valve (annulus). Annuloplasty may be done with other techniques to repair a heart valve.
• Valvuloplasty. This catheter procedure is used to repair a mitral valve with a narrowed opening. Valvuloplasty might be done even if you don't have symptoms. The surgeon inserts a catheter with a balloon on the tip into an artery in the arm or groin and guides the catheter to the mitral valve. The balloon is inflated, widening the mitral valve opening. The balloon is deflated, and the catheter and balloon are removed.
• Mitral valve clip. In this procedure, a doctor specializing in heart diseases (cardiologist) guides a catheter with a clip on its end to the mitral valve through an artery in the groin. The clip is used to improve the closure of the mitral valve leaflets and to reduce the amount of regurgitation. This procedure is an option for people who have severe mitral valve regurgitation or who aren't a good candidate for mitral valve surgery.

Mitral valve replacement

During mitral valve replacement, the surgeon removes the mitral valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue (biological tissue valve).

Sometimes, a heart catheter procedure is done to place a replacement valve into a biological tissue valve that no longer works well. This is called a valve-in-valve procedure.

If you had mitral valve replacement with a mechanical valve, you'll need to take blood thinners for life to prevent blood clots. Biological tissue valves break down (degenerate) over time and usually need to be replaced.

Lifestyle and home remedies

Your health care provider may suggest that you make several heart-healthy lifestyle changes. Take these steps:

• Manage blood pressure. Control of high blood pressure is important if you have mitral valve regurgitation.
• Eat a heart-healthy diet. Food doesn't directly affect mitral valve regurgitation. But a healthy diet can help prevent other heart disease that can weaken the heart muscle. Eat foods that are low in saturated and trans fats, sugar, salt, and refined grains, such as white bread. Eat a variety of vegetables and fruits, whole grains, and proteins, such as lean meats, fish and nuts.
• Get regular exercise. How long and hard you're able to exercise can depend on whether you have mild, moderate or severe mitral valve regurgitation. Ask your health care provider for guidance before starting to exercise, especially if you're considering competitive sports.
• Maintain a healthy weight. You and your health care provider can discuss a healthy weight goal.
• Prevent infective endocarditis. If you've had mitral valve replacement, your health care provider will recommend that you take antibiotics before dental procedures to prevent an infection called infective endocarditis.
• Avoid or limit alcohol. Heavy alcohol use can cause arrhythmias and can make your symptoms worse. Excessive alcohol use can also cause cardiomyopathy, a condition of weakened heart muscle that leads to mitral regurgitation. Ask your health care provider about the effects of drinking alcohol.
• Avoid tobacco. If you smoke, quit. Ask your health care provider about resources to help you quit smoking. Joining a support group may be helpful.
• Get regular health checkups. Establish a regular schedule with your cardiologist or primary care provider. Tell your health care provider if you have any changes in your signs or symptoms.

Women with mitral valve regurgitation should talk to their health care provider before trying to get pregnant. Pregnancy causes the heart to work harder. How a heart with mitral valve regurgitation tolerates this extra work depends on the degree of regurgitation and how well the heart pumps.

Preparing for an appointment

If you think you have mitral valve regurgitation, make an appointment to see your health care provider. Here's some information to help you prepare for your appointment.

What you can do

• Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do beforehand.
• Write down your symptoms, including any that seem unrelated to mitral valve regurgitation.
• Write down key personal information, including a family history of heart disease, heart defects, genetic disorders, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
• Make a list of all medications, vitamins and supplements you take.
• Take a family member or friend along, if possible, to help you remember information you receive.
• Be prepared to discuss your diet and exercise habits. If you don't already eat well and exercise, be ready to talk to your health care provider about challenges you might face in getting started.
• Write down questions to ask your health care provider.

For mitral valve regurgitation, some basic questions to ask your health care provider include:

• What is likely causing my condition?
• What are other possible causes for my symptoms?
• What tests will I need?
• What's the best treatment?
• What are the alternatives to the primary approach you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there restrictions I need to follow?
• If I need surgery, which surgeon do you recommend for mitral valve repair?
• Are there brochures or other printed material I can take with me? What websites do you recommend?

Don't hesitate to ask other questions you have.

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, including:

• When did your symptoms begin?
• Are your symptoms constant or do they come and go?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

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