Mitral Valve Regurgitation

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Overview

The heart

What is mitral valve regurgitation?

Mitral valve regurgitation means that one of the valves in your heart—the mitral valve—is letting blood leak backward into the heart.

Heart valves work like one-way gates, helping blood flow in one direction between heart chambers or in and out of the heart. The mitral valve is on the left side of your heart. It lets blood flow from the upper to the lower heart chamber.

See a picture of mitral valve regurgitation.

When the mitral valve is damaged—for example, by an infection—it may no longer close tightly. This lets blood leak backward, or regurgitate, into the upper chamber. Your heart has to work harder to pump this extra blood.

Small leaks are usually not a problem. But more severe cases weaken the heart over time and can lead to heart failure.

What causes mitral valve regurgitation?

There are two forms of mitral valve regurgitation: chronic and acute.

  • Chronic mitral valve regurgitation, the most common type, develops slowly.
    • Primary regurgitation means there is a problem with the anatomy of the valve. The valve does not work well and does not close tightly. This might happen because of problems like calcium buildup on the valve. It can also happen in people who have mitral valve prolapse.
    • Secondary regurgitation means another heart problem causes the valve to not close tightly. The anatomy of the valve is typically normal. The heart problem, such as heart failure, affects the heart muscle, and this causes regurgitation.
  • Acute mitral valve regurgitation develops quickly and can be life-threatening. It happens when the valve or nearby tissue ruptures suddenly. Instead of a slow leak, blood builds up quickly in the left side of the heart. Your heart doesn't have time to adjust to this sudden buildup of blood the way it does with the slow buildup of blood in chronic regurgitation. Common causes of acute regurgitation are heart attack and a heart infection called endocarditis.

What are the symptoms?

Symptoms of mitral valve regurgitation include being tired or short of breath when you are active.

If your heart weakens because of your mitral valve, you may start to have symptoms of heart failure. Call your doctor if you start to have symptoms or if your symptoms change. Symptoms include:

  • Shortness of breath with activity, which later develops into shortness of breath at rest and at night.
  • Extreme tiredness and weakness.
  • A buildup of fluid in the legs and feet, called edema.

Acute mitral valve regurgitation is an emergency. Symptoms come on rapidly. Symptoms include severe shortness of breath, fast heart rate, lightheadedness, weakness, confusion, and chest pain.

How is mitral valve regurgitation diagnosed?

Because you may not have symptoms, a specific type of heart murmur may be the first sign your doctor notices. Further tests will be needed to check your heart. Tests may include:

  • Echocardiograms, which use ultrasound to see how serious the valve problem is.
  • An electrocardiogram (EKG, ECG) to look for abnormal heart rhythms.
  • A chest X-ray to check heart size.
  • Cardiac catheterization to see how serious the problem is.

Finding out that something is wrong with your heart is scary. You may feel depressed and worried. This is a common reaction. Sometimes it helps to talk to others who have similar problems. Ask your doctor about support groups in your area.

How is it treated?

Treatment for chronic cases includes regular tests to check how well the valve and the heart are working. You may take medicines to treat complications. You may take medicine to treat a heart problem that is causing the regurgitation.

You may need surgery to repair or replace your mitral valve. Your doctor will check many things to see if surgery is right for you. These things include the cause of the regurgitation, the anatomy of the valve, if you have symptoms, and how well your heart is pumping blood.

If you have chronic mitral valve regurgitation, your doctor may want you to make some lifestyle changes to help keep your heart healthy. He or she may advise you to:

  • Quit smoking and stay away from secondhand smoke.
  • Follow a heart-healthy diet and limit sodium.
  • Be active. Ask your doctor what level and type of exercise is safe for you. You may need to avoid intense activity.
  • Stay at a healthy weight, or lose weight if you need to.

Treatment for acute mitral valve regurgitation occurs while you are in the hospital or the emergency room. You need surgery right away to repair or replace the valve.

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Cause

There are two forms of mitral valve regurgitation (MR): chronic and acute. Chronic mitral valve regurgitation develops slowly over several years. Acute MR develops suddenly.

Chronic mitral valve regurgitation

There are two types of chronic mitral valve regurgitation: primary and secondary.

Primary means there is a problem with the anatomy of the valve. The valve does not work well and does not close tightly.

Primary regurgitation can be caused by:

  • Calcium buildup as a person ages. The mitral valve may become hard, or calcified, around the tough ring of tissue (annulus) to which the mitral valve flaps are attached. Normally the mitral annulus is soft and flexible. But as a person ages, calcium may build up inside the annulus. This hardened mitral valve cannot close completely, and blood leaks backward (regurgitates) into the upper left chamber of the heart (atrium).
  • Mitral valve prolapse.
  • Heart defects or abnormalities present at birth (congenital heart defects).
  • Endocarditis, which is an infection of the lining of the heart and heart valves. This infection can scar the mitral valve.
  • Autoimmune diseases that can damage the mitral valve, such as rheumatoid arthritis or lupus.
  • Marfan's syndrome, which is a connective tissue disease.
  • Rheumatic fever, which can scar the heart valves. This can prevent them from closing completely.
  • Previous use of the weight-loss medicine fen-phen (phentermine and fenfluramine/dexfenfluramine), which appears to increase the risk of heart valve disease.
  • Injury to the heart or the chordae tendineae, which are strong, flexible cords that control the opening and closing of the mitral valve.

Secondary means another heart problem is causing the valve to not close tightly. The anatomy of the valve is typically normal. The heart problem affects the heart muscle, and this causes regurgitation.

Secondary regurgitation can be caused by heart problems that affect the left ventricle. These problems include:

Acute mitral valve regurgitation

Acute mitral valve regurgitation occurs when the mitral valve or one of its supporting structures ruptures suddenly, creating an immediate overload of blood volume and pressure in the left side of the heart. Your heart doesn't have time to adjust to the increased volume and pressure of blood (as it does in chronic MR).

Causes of sudden rupture include:

  • Injury to the chordae tendineae. Endocarditis may also cause the chordae tendineae to rupture.
  • Injury to the chest.
  • Heart attack, which may cause the rupture of the muscle (papillary) surrounding the valve.
  • Problems with a prosthetic mitral valve.
  • Perforation of the mitral valve flap (leaflet), caused by endocarditis.

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Symptoms

Symptoms of chronic mitral valve regurgitation (MR) may take decades to appear. With acute MR, symptoms come on suddenly, and you are critically ill.

Call your doctor right away if you have new or different symptoms. These include:

  • Shortness of breath with exertion, which may later develop into shortness of breath at rest and at night.
  • Fatigue and weakness.
  • Fluid buildup in the legs and feet.
  • Heart palpitations, if atrial fibrillation develops.

Chronic mitral valve regurgitation

Primary MR. If you have mild-to-moderate primary MR, you may not have symptoms. If you have severe disease, you may have symptoms when you are active. Symptoms include:

  • Fatigue and weakness.
  • Shortness of breath.

Secondary MR. If you have secondary MR, you likely have symptoms of the heart problem that has led to the regurgitation. You may have symptoms of heart failure or coronary artery disease.

Acute mitral valve regurgitation

Acute mitral valve regurgitation is an emergency. Symptoms of acute mitral valve regurgitation appear suddenly. Most people who develop acute MR are already in the hospital or emergency room because of another heart problem. Symptoms include severe shortness of breath, fast heart rate, lightheadedness, weakness, confusion, and chest pain.

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What Increases Your Risk

Risk factors for mitral valve regurgitation (MR) include:

  • Age. Wear and tear of the mitral valve occurs over time. This increases the likelihood of blood leaking back into the atrium.
  • Having mitral valve prolapse.
  • Having had rheumatic fever, because it can cause scarring on the valve. This can result in incomplete closure.
  • Having heart failure or coronary artery disease. These problems can change the shape of the left ventricle and cause the valve to not close normally.

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When to Call a Doctor

Call 911 or other emergency services immediately if you or a person you are with has:

  • Symptoms of a heart attack, including chest pain or pressure.
  • Symptoms of stroke.
  • Loss of consciousness (syncope).
  • Symptoms of acute mitral valve regurgitation including severe shortness of breath, fast heart rate, lightheadedness, weakness, confusion, and chest pain.

Call a doctor immediately if you have:

  • Symptoms of heart failure, such as shortness of breath, fatigue, and swelling in the legs and feet.
  • Mitral valve regurgitation (MR) and are having symptoms of infection such as fever with no other obvious cause. Be alert for signs of infection if you have recently have had any dental, diagnostic, or surgical procedure.
  • Irregular heartbeats.
  • Fainting episodes.
  • Palpitations.
  • Shortness of breath.
  • A decreased ability to exercise at your usual level.
  • Excessive fatigue (without other explanation).

If you are coughing up blood, call a doctor immediately.

Watchful waiting

Watchful waiting is a wait-and-see approach. If you do not have symptoms of MR, your doctor will still want to see you for regular checkups. Your doctor will want to see you as soon as you have symptoms for the first time. If your doctor has talked with you about what to do if you have symptoms, follow your doctor's instructions. Contact your doctor if your symptoms get worse.

Who to see

Health professionals who can evaluate symptoms that may be related to mitral valve regurgitation include:

They frequently can also order the tests needed for further evaluation of symptoms.

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Exams and Tests

Chronic mitral valve regurgitation (MR) can be difficult to diagnose. It is a "quiet" condition and often has no symptoms, or your symptoms may be confused with other heart-related conditions.

Chronic MR is often diagnosed during a routine checkup or a visit to the doctor for another condition. A heart murmur may be the first sign leading your doctor to the diagnosis, especially if you have no other symptoms.

Acute MR causes sudden symptoms and is much less common than chronic mitral valve regurgitation. It is usually diagnosed while you are already hospitalized or in the emergency room.

When your doctor suspects you have MR, he or she will discuss your medical history, do a physical exam, and likely order tests to check your heart. Your doctor uses the information to find out how severe your MR is. For more information, see Mitral Valve Regurgitation: Severity.

Medical history and physical exam

To find out the severity of your MR, your doctor will ask you to describe the symptoms you are experiencing, such as shortness of breath, fatigue, or chest pain.

During the physical exam, the doctor will take your blood pressure, check your pulse, listen to your heart and lungs, look at the veins in your neck (jugular veins), and check your legs and feet for fluid buildup (edema).

Echocardiogram

Echocardiogram (sometimes called an echo or echocardiography) is a type of ultrasound exam. It helps your doctor find out how severe your MR is. Also, echocardiography can help determine whether the heart's main pumping chamber (left ventricle) is functioning properly, whether any structural problems exist that may affect the mitral valve, and whether the chambers of the heart are enlarged.

Electrocardiogram

An electrocardiogram (EKG, ECG) is a test that measures the electrical signals that control the rhythm of your heartbeat.

Although the EKG may reveal abnormal electrical activity in the heart, further testing is often still needed to find out the severity of MR and to confirm whether MR is causing enlargement of the left ventricle. The result of an EKG is often normal in people who have mild MR.

Imaging tests

A chest X-ray may be done to evaluate heart size and to assess symptoms of MR, such as shortness of breath. Calcium deposits on the heart valves may sometimes be seen on a chest X-ray.

A magnetic resonance imaging (MRI) test may be done to see how well the heart is pumping blood and to check how severe the MR is.

Cardiac catheterization

Cardiac catheterization may be done to confirm the severity of mitral valve leakage seen on an echocardiogram.

Regular checkups

How often you see your doctor and what tests are done will be determined by how severe your chronic mitral valve regurgitation is.

Recommended frequency for checking mitral valve regurgitation 1

Severity of mitral regurgitation

How often you should have an echocardiogram

Mild

Every 3 to 5 years

Moderate

Every 1 to 2 years

Severe

At least every 6 to 12 months

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Treatment Overview

Treatment for chronic mitral valve regurgitation (MR) includes monitoring your heart function and symptoms. It may include treating symptoms as they develop. If another heart problem has caused the regurgitation, you will get treatment for that heart problem. If MR becomes severe, the mitral valve may need to be repaired or replaced.

Treatment for acute MR is immediate. Medicines and urgent surgery are usually needed.

Chronic regurgitation

Treatment depends on whether you have primary MR or secondary MR. It also depends on if you have symptoms or complications and how severe the regurgitation is.

Monitoring. If you don't have symptoms and you only have mild-to-moderate regurgitation, your doctor may only monitor your heart and valve function with an echocardiogram. You will see your doctor regularly. How often you get this test depends on the severity of regurgitation. For more information, see Exams and Tests.

Medicine. Your doctor may prescribe medicines to treat complications or treat the heart problem that caused the mitral regurgitation. For more information, see Medications.

Surgery. Surgery may be done to repair or replace the mitral valve. For more information, see Surgery.

Acute regurgitation

Initial treatment for acute MR includes medicines as needed to stabilize your condition. If medicines don't help, an intra-aortic balloon pump may be used for a short time to help circulate blood and ease the workload on your heart. Surgery may be done immediately to replace or repair the valve.

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Ongoing Concerns

Chronic primary mitral valve regurgitation (MR) develops slowly. And most people go years without having any symptoms. Before symptoms start, your condition may not be serious and you generally feel good. But even during this time, MR is doing irreversible damage to your heart. Because of this ongoing damage, your doctor may suggest surgery before you start having symptoms. Although it may be difficult to think about surgery when you feel well, not having surgery could lead to heart failure.

You will begin to have symptoms of chronic MR when your heart begins to weaken. A variety of medicines are available to treat your symptoms as MR progresses and to prevent complications.

Complications

People with mitral valve regurgitation sometimes develop serious complications including:

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Living With Mitral Valve Regurgitation

Make healthy lifestyle changes

  • If you smoke, try to quit. Medicines and counseling can help you quit for good. Avoid secondhand smoke too.
  • Your doctor will also recommend that you follow a heart-healthy diet and limit how much sodium you eat.
  • Be active, but ask your doctor what level of exercise is safe for you. You may need to be cautious about physical activity if you have symptoms, irregular heart rhythms, or changes in your heart size or function. But regular activity, even low-level activity such as walking, will help keep your heart healthy. If you want to start being more active, talk to your doctor first. Your doctor will help you create a safe exercise plan. For more information, see Mitral Valve Regurgitation and Exercise.
  • If you need to lose weight, try to reach and stay at a healthy weight. For help, see the topic Weight Management.

Take care of yourself

  • See your doctor right away if you have new symptoms or symptoms that get worse. For more information, see When to Call a Doctor.
  • See your doctor regularly. And get the tests you need, such as echocardiograms, to assess your heart. For more information, see Exams and Tests.
  • Manage other health problems including high blood pressure, diabetes, and high cholesterol.
  • Practice good dental hygiene and have regular checkups. Good dental health is especially important, because bacteria can spread from infected teeth and gums to the heart valves.
  • Get a flu vaccine every year. Get a pneumococcal vaccine shot. If you have had one before, ask your doctor if you need another dose.
  • Talk with your doctor if you have concerns about sex and your heart. Your doctor can help you know if or when it's okay for you to have sex.

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Medications

Medicines do not prevent or correct the damage to the heart caused by mitral valve regurgitation (MR). For chronic regurgitation, they might be used to treat complications of mitral regurgitation. They might be used to help treat the heart problem that has caused secondary MR. In acute regurgitation, medicine is used as emergency treatment before surgery.

Chronic regurgitation

In chronic MR, you may take medicine if you have symptoms and a low ejection fraction. You may take medicine to treat heart failure.

Medicine after surgery

Antibiotics. If you have an artificial valve, you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis. You will likely take antibiotics after surgery to repair or replace a valve. If you have had rheumatic fever, you may take antibiotics to avoid getting it again.

Blood thinners. Blood thinners prevent blood clots after surgery. Blood thinners include antiplatelet medicine, such as aspirin, or anticoagulant medicine, such as warfarin. If you have an artificial heart valve, you may need to take this medicine for the rest of your life.

Acute regurgitation

In acute MR, medicines are used in the hospital to stabilize your condition until you can have surgery to replace or repair the valve.

Complications

Medicines are used to prevent or treat complications of mitral regurgitation such as atrial fibrillation or heart failure. For more information, see the topics:

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Surgery

With chronic mitral valve regurgitation (MR), surgery to repair or replace the mitral valve might be recommended. Whether surgery is right for you depends on many things including the cause of MR.

With acute MR, urgent surgery to repair or replace the valve is usually needed. In some cases, surgery to correct the cause of acute MR may also be needed.

Chronic regurgitation

Primary MR. Surgery is the only cure for primary MR, because the abnormal shape of the mitral valve is causing the regurgitation.

Your doctor will check many things to see if surgery is right for you. Your doctor may check to see if:

  • Your valve can be repaired with surgery.
  • You have symptoms.
  • You have severe regurgitation.
  • Your heart has pumping problems (low ejection fraction).
  • Your left ventricle is larger than normal.

Repair is typically preferred over replacement. The decision between repairing or replacing the valve depends on the type of damage you have. For more information, see the topic Mitral Valve Regurgitation: Repair or Replace the Valve.

Secondary MR. Surgery cannot cure secondary MR, because another heart problem is causing the mitral valve to not close properly. Treatment of the heart problem, such as heart failure, may be the right treatment for you. Some people might benefit from surgery to repair or replace the mitral valve.

Your doctor will check many things to see if surgery is right for you. Your doctor may check to see if:

  • You have severe symptoms of heart failure.
  • You have severe regurgitation.
  • You are having heart surgery for another problem.

Repair

To repair the valve, the surgeon may:

  • Reshape the valve by removing excess valve tissue.
  • Add support to the valve ring by adding tissue or a collar-shaped structure around the base of the valve.
  • Attach the valve to nearby cordlike heart tissues (chordal transposition).

Replace

With replacement, the badly damaged valve is removed and a mechanical (plastic or metal) or bioprosthetic valve (usually made from pig tissue) is sewn into place. Before you have valve replacement surgery, you and your doctor will decide on which type of valve is right for you.

For more information, see:

Mitral Valve Replacement Surgery.
Click here to view a Decision Point. Heart Valve Problems: Should I Choose a Mechanical Valve or Tissue Valve to Replace My Heart Valve?

Transcatheter repair

A transcatheter procedure is a new way to repair a mitral valve. It does not require open-heart surgery. It is a minimally invasive procedure. A doctor uses catheters in blood vessels to insert a device in the valve. The device helps keep blood from leaking backward. This may relieve symptoms and improve quality of life. This procedure is available in a small number of hospitals. And it is not right for everyone. It might be done for a person who can't have surgery or for a person who has a high risk of serious problems from surgery.2

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Other Places To Get Help

Organizations

National Heart, Lung, and Blood Institute (NHLBI) (U.S.)
www.nhlbi.nih.gov
American Heart Association (AHA)
www.heart.org

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References

Citations

  1. Nishimura RA, et al. (2014). 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, published online March 3, 2014. DOI: 10.1161/CIR.0000000000000031. Accessed May 1, 2014.
  2. A percutaneous device (MitraClip) for mitral regurgitation (2013). Medical Letter on Drugs and Therapeutics, 55(1432): 103.

Other Works Consulted

  • Adams DH, et al. (2011). Mitral valve regurgitation. In V Fuster et al., eds., Hurst’s The Heart, 13th ed., vol. 2, pp. 1721–1737. New York: McGraw-Hill.
  • Badiwala MV, et al. (2009). Surgical management of ischemic mitral valve regurgitation. Circulation, 120(12): 1287–1293.
  • Nishimura RA, et al. (2014). 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, published online March 3, 2014. DOI: 10.1161/CIR.0000000000000031. Accessed May 1, 2014.
  • Oakley RE, et al. (2008). Choice of prosthetic heart valve in today's practice. Circulation, 117(2): 253–256.
  • Otto CM, Bonow RO (2012). Valvular heart disease. In RO Bonow et al., eds., Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed., vol. 2, pp. 1468–1539. Philadelphia: Saunders.
  • Rodriguez L, Gillinov AM (2007). Mitral valve disease. In EJ Topol, ed., Textbook of Cardiovascular Medicine. Philadelphia: Lippincott Williams and Wilkins.
  • Stout KK, Verrier ED (2009). Acute valvular regurgitation. Circulation, 119(25): 3232–3241.
  • Whitlock RP, et al. (2012). Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic therapy and prevention of thrombosis, 9th ed.—American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2, Suppl): e576S–e600S.

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Credits

ByHealthwise Staff
Primary Medical Reviewer Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology
Specialist Medical Reviewer John A. McPherson, MD, FACC, FSCAI - Cardiology

Current as ofAugust 8, 2014