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Medical therapy alone for patients >75 years of age with MR is preferred, owing to increased operative mortality and decreased survival (compared with those with AS), especially with preexisting CAD or need for MV replacement.
MV repair is preferable than MV replacement.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Acute MR: Stabilize ABCs (airway, breathing, circulation). Initiate IV, O2, and monitoring. Nitroprusside (+dobutamine and/or aortic balloon counterpulsation if hypotensive). Treat underlying causes (e.g., MI). Treat acute pulmonary edema with furosemide and morphine. Obtain urgent surgical consultation.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Chronic MR: asymptomatic
- Mild MR with normal LV size and function and no pulmonary hypertension: Annual clinical evaluation to assess symptom progression and TTE every 3 to 5 years to assess MR severity, LV size and function.
- Moderate MR: annual clinical evaluation and TTE every 1 to 2 years
- Severe MR: clinical evaluation and TTE every 6 to 12 months
- Consider serial CXRs and ECGs, and consider stress test if exercise capacity is doubtful.
PATIENT EDUCATION
- Exercise after MV repair: Avoid sports with risk for bodily contact or trauma. Low-intensity competitive sports are allowed.
- Competitive athletes with MR
- Asymptomatic with normal LV size and function, normal pulmonary artery pressures, and sinus rhythm: no restrictions
- Mildly symptomatic and those with LV dilatation: Activities with low to moderate dynamic and static cardiac demand allowed
- AF and anticoagulation: no contact sports
PROGNOSIS
- Acute, severe MR: Mortality risk with surgery is 50%; mortality risk with medical therapy alone is 75% in first 24 hours and 95% at 2 weeks.
- Chronic MR: asymptomatic severe MR with normal LVEF: 10% yearly rate of progression to symptoms and subnormal resting LVEF. Symptomatic severe MR: 8-year survival rate, 33% without surgery; mortality rate, 5% yearly
Pregnancy Considerations
MR with NYHA functional class III " IV at high risk for maternal and/or fetal risk
COMPLICATIONS
Acute pulmonary edema, CHF, AF, bleeding risk with anticoagulation, endocarditis, sudden cardiac death
REFERENCES
11 Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet. 2009;373(9672):1382 " 1394.22 Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(23):e521 " e643.33 Foster E. Clinical practice. Mitral regurgitation due to degenerative mitral-valve disease. N Engl J Med. 2010;363(2):156 " 165.
ADDITIONAL READING
- Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014;370(1):23 " 32.
- Feldman T, Young A. Percutaneous approaches to valve repair for mitral regurgitation. J Am Coll Cardiol. 2014;63(20):2057 " 2068.
- Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J. 2012;33(19):2451 " 2496.
- Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013;128(16):e240 " e327.
CODES
ICD10
- I34.0 Nonrheumatic mitral (valve) insufficiency
- I05.1 Rheumatic mitral insufficiency
- Q23.3 Congenital mitral insufficiency
ICD9
- 424.0 Mitral valve disorders
- 394.1 Rheumatic mitral insufficiency
- 746.6 Congenital mitral insufficiency
SNOMED
- 48724000 Mitral valve regurgitation (disorder)
- 31085000 Rheumatic mitral regurgitation (disorder)
- 29928006 Congenital insufficiency of mitral valve (disorder)
- 373116009 Acute mitral regurgitation
- 194978002 Non-rheumatic mitral regurgitation (disorder)
CLINICAL PEARLS
- Follow-up for mild to moderate MR: serial exam and/or echo unless LV structural changes
- Severe MR is usually managed with MV repair.
- Endocarditis prophylaxis is not recommended.