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Mitral valve regurgitation

Overview

Mitral valve regurgitation — also called mitral regurgitation, mitral insufficiency or mitral incompetence — is a condition in which your heart's mitral valve doesn't close tightly, allowing blood to flow backward in your heart. If the mitral valve regurgitation is significant, blood can't move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath.

Treatment of mitral valve regurgitation depends on how severe your condition is, whether it's getting worse and whether you have symptoms. For mild leakage, treatment is usually not necessary.

You 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). Even people without symptoms may need to be evaluated by a cardiologist and surgeon trained in mitral valve disease to determine whether early intervention may be beneficial.

Symptoms

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:

  • Abnormal heart sound (heart murmur) heard through a stethoscope
  • Shortness of breath (dyspnea), especially when you have been very active or when you lie down
  • Fatigue
  • Heart palpitations — sensations of a rapid, fluttering heartbeat
  • Swollen feet or ankles

Mitral valve regurgitation is often mild and progresses slowly. You may have no symptoms for many years and be unaware that you have this condition, and it might not progress.

Your doctor might first suspect you have mitral valve regurgitation upon detecting a heart murmur. Sometimes, however, the problem develops quickly, and you may experience a sudden onset of severe signs and symptoms.

When to see a doctor

If your doctor hears a heart murmur when listening to your heart with a stethoscope, he or she may recommend that you visit a cardiologist and get an echocardiogram. If you develop symptoms that suggest mitral valve regurgitation or another problem with your heart, see your doctor right away. Sometimes the first indications are actually those of mitral valve regurgitation's complications, including heart failure, a condition in which your heart can't pump enough blood to meet your body's needs.

Causes

Your heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps (leaflets or cusps) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly, disrupting the blood flow through your heart to your body.

In mitral valve regurgitation, the valve between the upper left heart chamber (left atrium) and the lower left heart chamber (left ventricle) doesn't close tightly, causing blood to leak backward into the left atrium (regurgitation).

Mitral valve regurgitation causes

Mitral valve regurgitation can be caused by problems with the mitral valve, also called primary mitral valve regurgitation. Diseases of the left ventricle can lead to secondary or functional mitral valve regurgitation.

Possible causes of mitral valve regurgitation include:

  • 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 flaps 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 the United States, 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 (Cafergot, Migergot) 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.
Chambers and valves of the heart

A normal heart has two upper and two lower chambers. The upper chambers, the right and left atria, receive incoming blood. The lower chambers, the more muscular right and left ventricles, pump blood out of your heart. The heart valves, which keep blood flowing in the right direction, are gates at the chamber openings.

Mitral valve prolapse and regurgitation

The mitral valve separates the two chambers (atrium and ventricle) of the left side of the heart. In mitral valve prolapse, the leaflets of the mitral valve bulge (prolapse) into the left atrium like a parachute during the heart's contraction. Sometimes mitral valve prolapse causes blood to leak back into the atrium from the ventricle, which is called mitral valve regurgitation.

Risk factors

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

  • A history of mitral valve prolapse or mitral valve stenosis. However, having either condition doesn't necessarily mean you'll develop mitral valve regurgitation. A family history of valve disease also can increase risk.
  • A heart attack. A heart attack can damage your 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 (Cafergot, Migergot) 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 they cause 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.

Complications

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

  • Heart failure. Heart failure results when your heart can't pump enough blood to meet your 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 beat. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure.

    Also, pressure builds in your lungs, leading to fluid accumulation, which strains the right side of the heart.

  • Atrial fibrillation. The stretching and enlargement of your heart's left atrium may lead to this heart rhythm irregularity in which the upper chambers of your heart beat chaotically and rapidly. Atrial fibrillation can cause blood clots, which can break loose from your heart and travel to other parts of your body, causing serious problems, such as a stroke if a clot blocks a blood vessel in your brain.
  • Pulmonary hypertension. If you have long-term untreated or improperly treated mitral regurgitation, you can develop a type of high blood pressure that affects the vessels 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 heart failure on the right side of the heart.

Diagnosis

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

Your doctor will then decide which tests are needed to make a diagnosis. For testing, you may be referred to a cardiologist.

Tests

Common tests to diagnose mitral valve regurgitation include:

  • Echocardiogram. This test is commonly used to diagnose mitral valve regurgitation. In this test, sound waves directed at your heart from a wandlike device (transducer) held on your chest produce video images of your heart in motion.

    This test assesses the structure of your heart, the mitral valve and the blood flow through your heart. An echocardiogram helps your 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 your esophagus, which allows a closer look at the mitral valve than a regular echocardiogram does.

  • Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on your skin measure electrical impulses from your heart. An ECG can detect enlarged chambers of your heart, heart disease and abnormal heart rhythms.
  • Chest X-ray. This enables your doctor to determine whether the left atrium or the left ventricle is enlarged — possible indicators of mitral valve regurgitation — and the condition of your lungs.
  • Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create detailed images of your heart. This test may be used to determine the severity of your condition and assess the size and function of your lower left heart chamber (left ventricle).
  • Cardiac CT. A CT angiogram may be performed of the chest, abdomen and pelvis to determine whether you're a candidate for robotic mitral valve repair.
  • Exercise tests or stress tests. Different exercise tests help measure your activity tolerance and monitor your heart's response to physical exertion. If you are unable to exercise, medications to mimic the effect of exercise on your 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 in your arm or groin to an artery in your heart and injecting dye through the catheter to make the artery visible on an X-ray. This provides a detailed picture of your heart arteries and how your heart functions. It can also measure the pressure inside the heart chambers.

Treatment

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

A doctor trained in heart disease (cardiologist) will provide your care. If you have mitral valve regurgitation, 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 you to determine the most appropriate treatment for your condition.

Watchful waiting

Some people, especially those with mild regurgitation, might not need treatment. However, the condition may require monitoring by your doctor. You may need regular evaluations, with the frequency depending on the severity of your condition. Your doctor may also recommend making healthy lifestyle changes.

Medications

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

Medications may include:

  • Diuretics. These medications can relieve fluid accumulation in your lungs or legs, which can accompany mitral valve regurgitation.
  • Blood thinners. These medications can help prevent blood clots and may be used if you have atrial fibrillation.
  • High blood pressure medications. High blood pressure makes mitral valve regurgitation worse, so if you have high blood pressure, your doctor may prescribe medication to help lower it.

Surgery

Your mitral valve may need to be repaired or replaced. Doctors may suggest mitral valve repair or replacement even if you aren't experiencing symptoms, as this may prevent complications and improve outcomes. If you need surgery for another heart condition, your doctor may repair or replace the diseased mitral valve at the same time.

Mitral valve surgery is usually performed through a cut (incision) in 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.

Doctors at some medical centers may perform robot-assisted heart surgery, a type of minimally invasive heart surgery. In this type of surgery, surgeons view the heart in a magnified high-definition 3-D view on a video monitor and use robotic arms to duplicate specific maneuvers used in open-heart surgeries.

Your doctor will discuss with you whether mitral valve repair or mitral valve replacement may be most appropriate for your condition. He or she may also evaluate you to determine whether you're a candidate for minimally invasive heart surgery or open-heart surgery.

Doctors often may recommend mitral valve repair, as it preserves your own valve and may preserve heart function. However, if mitral valve repair isn't possible, doctors may need to perform mitral valve replacement.

Surgery options include:

Mitral valve repair

Surgeons can repair the valve by reconnecting valve flaps (leaflets), replacing the cords that support the valve, or removing excess valve tissue so that the leaflets can close tightly. Surgeons may often tighten or reinforce the ring around a valve (annulus) by implanting an artificial ring (annuloplasty band).

Doctors may use long, thin tubes (catheters) to repair the mitral valve in some cases. In one catheter procedure, doctors insert a catheter with a clip attached in an artery in the groin and guide it to the mitral valve. Doctors use the clip to reshape the valve. People who have severe symptoms of mitral valve regurgitation and who aren't candidates for surgery or who have high surgical risk may be considered for this procedure.

In another procedure, doctors may repair a previously replaced mitral valve that is leaking by inserting a device to plug the leak.

Mitral valve replacement

If your mitral valve can't be repaired, you may need mitral valve replacement. In mitral valve replacement, your surgeon removes the damaged valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue (biological tissue valve).

Biological tissue valves degenerate over time, and often eventually need to be replaced. People with mechanical valves need to take blood-thinning medications for life to prevent blood clots.

Your doctor can discuss the risks and benefits of each type of heart valve with you and discuss which valve may be appropriate for you.

Doctors continue to study catheter procedures to repair or replace mitral valves. Some medical centers may offer mitral valve replacement during a catheter procedure as part of a clinical trial for people with severe mitral valve disease who are aren't candidates for surgery. A catheter procedure can also be used to insert a replacement valve in a biological tissue replacement valve that is no longer working properly.

Talk to your doctor about what type of follow-up you need after surgery, and let your doctor know if you develop new symptoms or if your symptoms worsen after treatment.

Mitral valve repair

In mitral valve repair, the surgeon removes and repairs part of the damaged mitral valve to allow the valve to fully close and stop leaking. The surgeon may tighten or reinforce the ring around a valve (annulus) by implanting an artificial ring (annuloplasty band).

Mitral valve repair

In mitral valve repair, a doctor removes the portion of the mitral valve that doesn't close properly, as shown in the top image. Then a doctor sutures together the edges and cinches the circumference of the valve with an annuloplasty band to support the valve, as shown in the bottom image. The illustration shows mitral valve repair using robotic instruments.

Lifestyle and home remedies

Your doctor may suggest you incorporate several heart-healthy lifestyle changes into your life, including:

  • Keeping your blood pressure under control. Control of high blood pressure is important if you have mitral valve regurgitation.
  • Eating 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.
  • Maintaining a healthy weight. Keep your weight within a range recommended by your doctor.
  • Preventing infective endocarditis. If you have had a heart valve replaced, your doctor may recommend you take antibiotics before dental procedures to prevent an infection called infective endocarditis. Check with your doctor to find out if he or she recommends that you take antibiotics before dental procedures.
  • Cutting back on 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 doctor about the effects of drinking alcohol.
  • Avoiding tobacco. If you smoke, quit. Ask your doctor about resources to help you quit smoking. Joining a support group may be helpful.
  • Getting regular physical activity. How long and hard you're able to exercise depends on the severity of your condition and the intensity of exercise. Ask your doctor for guidance before starting to exercise, especially if you're considering competitive sports.
  • Seeing your doctor regularly. Establish a regular evaluation schedule with your cardiologist or primary care provider. Tell your doctor if you have any changes in your signs or symptoms.

If you're a woman with mitral valve regurgitation, it's important to talk to your doctor before you become 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 your heart pumps. Throughout your pregnancy and after delivery, your cardiologist and obstetrician should monitor you.

Coping and support

If you have mitral valve regurgitation, here are some steps that may help you cope:

  • Take medications as prescribed. Take your medications as directed by your doctor.
  • Get support. Having support from your family and friends can help you cope with your condition. Ask your doctor about support groups that may be helpful.
  • Stay active. It's a good idea to stay physically active. Your doctor may give you recommendations about how much and what type of exercise is appropriate for you.

Preparing for an appointment

If you think you have mitral valve regurgitation, make an appointment to see your doctor. 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. Someone who accompanies you can 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 doctor about challenges you might face in getting started.
  • Write down a list of questions to ask your doctor.

For mitral valve regurgitation, some basic questions to ask your doctor include:

  • What is likely causing my symptoms or condition?
  • What are other possible causes for my symptoms or condition?
  • 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?
  • Should I see a specialist?
  • If I need surgery, which surgeon do you recommend for mitral valve repair?
  • Is there a generic alternative to the medicine you're prescribing?
  • 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

Questions your doctor is likely to ask include:

  • When did your symptoms begin?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

Last updated: February 7th, 2018

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