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Mitral Regurgitation

- 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

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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 MRAsymptomatic with normal LV size and function, normal pulmonary artery pressures, and sinus rhythm: no restrictionsMildly 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.