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Mitral Valve Regurgitation

Definition


Disease: Mitral Valve Regurgitation Mitral Valve Regurgitation
Category: Cardiovascular diseases
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Disease Definition:

When the heart's mitral valve doesn't close tightly, allowing blood to flow backward in the heart, mitral valve regurgitation or mitral regurgitation happens. During a normal heartbeat, the mitral valve which is located between the heart's two left chambers, allows blood to flow forward through the heart. Mitral insufficiency or mitral incompetence is yet another name of mitral valve regurgitation.

Blood can't move through the heart or to the rest of the body as efficiently when the mitral valve doesn't function properly. Mitral valve regurgitation can make a person short of breath and tired.

The treatment of mitral valve regurgitation depends on the signs and symptoms, how severe the condition is and whether it's getting better or worse. Treatment may not be necessary for mild cases. However, for more severe cases, the patient may need heart surgery to repair or replace the valve.


When severe mitral valve regurgitation is left untreated, it may result in arrhythmias or heart failure.

Work Group:


Prepared by: Scientific Section

Symptoms, Causes

Symptoms:

The signs and symptoms of mitral valve regurgitation depend on how quickly the condition develops and the severity of the condition. The following are included in the symptoms of mitral valve regurgitation:

 

  • Heart palpitations, which are sensations of a rapid, fluttering heartbeat
  • Swollen feet or ankles
  • Shortness of breath, especially with exertion or when lying down
  • Excessive urination
  • Fatigue, especially during times of increased activity
  • Cough, especially at night or when lying down
  • Blood flowing turbulently through the heart (heart murmur)
  • Lightheadedness


Usually, mitral valve regurgitation is mild and progresses slowly. A person may not have any symptoms for decades and many not be aware that he/she has this condition.

Usually, this condition is first suspected when the doctor hears a new heart murmur. However, one may experience a sudden onset of more-severe symptoms and signs, because the problem develops quickly in some cases.

A person should see the doctor immediately when developing signs and symptoms that suggest mitral valve regurgitation or another problem with the heart. The signs of complications including heart failure are sometimes the first signs of mitral valve regurgitation. Causing fatigue, shortness of breath and fluid buildup, the condition in which the heart can't pump enough blood to the rest of the body is called heart failure. Mitral valve regurgitation is just one of a number of causes of this.

However, during a routine examination when the doctor listens to the heart of the patient with a stethoscope, mitral valve regurgitation can be discovered earlier. An abnormal heart sound (heart murmur) can be caused by mitral valve regurgitation.
Mitral valve regurgitation may not progress and never pose a serious threat to the health of the patient when it is mild. However, when it is severe, this condition may require corrective surgery and it may cause heart complications.

Causes:

The pump of the circulatory system is the heart and it has four chambers. Blood is received by the atria, which are the two upper chambers; and pumped by the ventricles, which are the two lower chambers.  

Aided by four heart valves, blood flows through the heart's chambers. These valves open and close in order to allow blood to flow through the heart in only one direction. There are two triangular-shaped flaps of tissue called leaflets in the mitral valve that lies between the two left chambers of the heart.

Heart valves open like a trapdoor. When the left atrium contracts, the leaflets of the mitral valve open, forcing blood into the left ventricle through those leaflets. The flaps close to prevent blood that has just passed into the left ventricle from flowing backward in the wrong direction when the left atrium relaxes between heart contractions.

Heart valves open and close fully when working properly. The mitral valve doesn't close tightly in mitral valve regurgitation. In this way, with each heartbeat, some blood from the left ventricle flows backward into the left atrium instead of forward into the aorta. This backflow of blood through the heart valve is called regurgitation.

WHAT CAUSES MITRAL VALVE REGURGITATION:
Many things may cause mitral valve regurgitation, such as:

Damaged Tissue Cords:
As a result of damage to the tissue cords that anchor the flaps of the mitral valve to the heart wall, mitral valve regurgitation may occur. Especially in people with mitral valve prolapse; these cords may stretch or suddenly tear over time. Substantial leakage through the mitral valve can be caused by a tear of these cords which may require repair by heart surgery.

Rheumatic Fever:
Leading to mitral valve regurgitation later in life, the mitral valve can be damaged by rheumatic fever, which is a complication of untreated strep throat that was once a common childhood illness in some countries. Rheumatic fever can damage the mitral valve in two main ways. The infection may cause scarring of the mitral leaflets, which may lead to regurgitation. Limiting the valve's ability to open, the infection may cause the leaflets of the valve to thicken as well. In a condition known as mitral valve stenosis, this causes narrowing of the valve. In countries where the use of antibiotics is not common, people with rheumatic fever, which is still common,  may have mitral valve regurgitation as well as mitral valve stenosis.

Untreated High Blood Pressure:
High blood pressure can cause the heart to work harder over time, and the left ventricle of the heart can gradually enlarge. Leakage can result in this case if the tissue around the mitral valve stretches.

Mitral Valve Prolapse:
The condition in which the leaflets and tendon-like cords supporting the mitral valve weaken is called mitral valve prolapse. This causes the valve leaflets to bulge (prolapse) up into the left atrium with each contraction of the left ventricle. The mitral valve may be prevented from closing tightly because of this common heart defect, which could lead to regurgitation. However, most people who have mitral valve prolapse never develop severe regurgitation, so this condition is common.

Prior Heart Attack:
Affecting the function of the valve, a heart attack can damage the area of the heart muscle that supports the mitral valve. As a matter of fact, a heart attack may result in a sudden and severe mitral valve regurgitation if the damage is extensive enough. Acute mitral valve regurgitation is what this sudden onset of regurgitation is sometimes called.

Wear and Tear on the Valve:
Sometimes, mitral valve regurgitation may be caused by age-related wear and tear on the valve because the mitral valve opens and shuts tens of thousands of times every day of a person's life.

Endocarditis:
As a result of endocarditis, an infection of the lining (endocardium) of the heart that can involve heart valves, the mitral valve may be damaged.

Congenital Heart Defects:
Some babies are born with damaged heart valves or other defects in their hearts.
The heart may weaken as a result of severe mitral valve regurgitation, regardless of its cause. Some blood flows backward into the left atrium instead of flowing forward into the aorta when the left ventricle contracts in a heart with mitral valve regurgitation. So, blood flow to the rest of the body decreases as a result. The left ventricle may enlarge (dilate) so that it can pump more blood with each heartbeat, as a reaction to this. This adaptation helps the heart beat with more force at first. However, sooner or later, the change may cause heart failure and heart rhythm irregularities, such as atrial fibrillation and it weakens the heart.


The risk of mitral valve regurgitation may increase due to:


Congenital Heart Disease:
Often babies born with heart defects may have more than one problem, such as an abnormal mitral valve and a hole in the upper chambers of the heart (atrial septal defect). Some people that are born with an abnormal mitral valve are prone to regurgitation.

Age:
Caused by natural deterioration of the valve, many people have some mitral valve regurgitation by middle age. However, in only a small percentage of older adults does mitral valve regurgitation cause symptoms.

Use of Certain Medications:
The risk of mitral regurgitation is increased in people who took pergolide (now removed from the market) and those who take ergotamine and similar medicines for migraines. With the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold, similar problems were noted.

Complications

Complications:

Mitral valve regurgitation may never cause problems when it's mild. However it may lead to the following complications if it's severe:

Pulmonary hypertension:
Pulmonary hypertension can develop if one has mitral regurgitation for many years and is treated improperly, or not treated at all. The type of high blood pressure that affects only the arteries in the lungs is called pulmonary hypertension. When tiny arteries in the lungs become blocked or narrowed, this serious illness begins. Increased resistance to the flow of blood in the lungs is caused by this, which in turn raises pressure within the pulmonary arteries.

Atrial fibrillation:
In this case, the heart's upper chambers (atria) beat chaotically and rapidly. Blood clots can result from atrial fibrillation. A stroke may be caused in case these clots break loose from the heart and travel through the bloodstream to the brain.  In people with mitral valve regurgitation, other irregular heartbeats (heart arrhythmias) may occur as well.

Heart failure:
The heart is unable to pump enough blood to meet the body's needs in heart failure. Due to the need to pump extra blood, severe mitral regurgitation places an extra strain on the heart. The left ventricle gets bigger and weakens if this condition is left untreated, which can result in heart failure. As a result of mitral valve regurgitation, fluid and pressure build up in the lungs and can eventually put a strain on the right side of the heart, leading to ankle swelling (edema). People with heart failure may wake up at night feeling short of breath, and they may experience fatigue and shortness of breath during the day.

Endocarditis:
The infection of the inner lining of the heart is called endocarditis. One of the heart valves is typically involved in the infection, especially if it is already damaged. The damaged mitral valve is more prone to infection than is the healthy valve. When bacteria from another part of the body spread through the bloodstream and lodge in the heart, a person may develop endocarditis. To prevent endocarditis, some people with mitral valve regurgitation were recommended taking antibiotics before certain dental or medical procedures; however, for most people with mitral valve prolapse or mitral valve regurgitation, antibiotics are no longer considered necessary.

Treatments:

The treatment of mitral valve regurgitation depends on how severe the condition is and if it's getting worse. Improving the function of the heart while avoiding future complications and minimizing the signs and symptoms is the goal of treatment.

OBSERVATION:
Treatment is not needed for some people, especially those with mild regurgitation. However, the condition may require monitoring by the doctor, even if the patient doesn't have signs and symptoms with mitral valve regurgitation. With the frequency depending on the amount of regurgitation, the patient may need regular evaluations.

The patient should pay special attention to the symptoms in case he/she ends up needing treatment while working with the doctor. So, observation isn't the same as ignoring the condition.

MEDICATIONS:
A deformity of a mitral valve can't be corrected by medication. However, to relieve fluid accumulation in the legs or lungs, which can accompany mitral valve regurgitation, medications like diuretics are available. Medications to help lower the blood pressure may be prescribed if the patient has high blood pressure, as this high blood pressure makes mitral valve regurgitation worse. Fluid buildup can be prevented and blood pressure may be controlled by following a low-salt diet.

SURGERY:
The mitral valve may need to be surgically replaced or repaired. The patient may question the need for open-heart surgery if he/she feels well. However, because the heart is good at counteracting problems caused by a leaky mitral valve, one may have bad mitral valve regurgitation and yet feel well.    

It's important that the patient undergoes surgery if the doctor feels it will help that patient avoid future problems, and to closely monitor mitral valve regurgitation, because the heart may become so weakened or become damaged beyond repair that surgery wouldn't help if the patient waits too long to have surgery.

The pros and cons of surgery can be discussed with the doctor. The following are included in the surgery options:

Valve repair:
The surgery that preserves the patient's own valve is called mitral valve repair. To correct the condition, this is the preferred surgical treatment for most people with mitral valve prolapse.

"Leaflets" is the name of the two triangular-shaped flaps of tissue that the mitral valve consists of. Through a ring called the annulus, the leaflets of the mitral valve connect to the heart muscle. To eliminate backward blood flow, the surgeon can modify the original valve (valvuloplasty). By removing excess valve tissue or by reconnecting valve leaflets so that the leaflets can close tightly, surgeons can repair the valve as well. Replacing or tightening the ring around the valve (annulus) is included in repairing the valve sometimes; this is called an annuloplasty. Having an experienced surgeon to perform mitral valve repair is important.

Valve replacement:
When valve repair isn't possible, valve replacement surgery is performed. The damaged mitral valve is replaced by an artificial (prosthetic) valve in this surgery. Tissue and mechanical are the two types of artificial valves.

Mechanical valves, which are made of metal, may last a long time. However, to prevent blood clots from forming on the valve, the patient must use an anticoagulant medication such as warfarin for the rest of his/her life if he/she has a mechanical valve, because a blood clot could travel to the brain and cause a stroke if it forms on the valve and breaks free.  

From animal tissue such as a pig's heart valve, tissue valves are made. These types of valves are called bioprostheses. That the patient doesn't have to use long-term anticoagulant medication is an advantage of the tissue valve, but they may wear out over time and need replacement.

Open-heart surgery under general anesthesia is required in mitral valve replacement or repair. A cut that's the length of the breastbone (sternum) is made and the heart of the patient is exposed and connected to a heart-lung machine that assumes the patient's breathing and blood circulation functions during the procedure in this traditional open-heart surgery. Then the valve is repaired or replaced. The patient will spend one or more days in an intensive care unit, where his/her heart function and general recovery are closely monitored after the operation.

With surgery, mitral valve regurgitation can be eliminated; however, some people may continue to have some leakage. How well the patient does depends on the heart's pumping function, how much regurgitation is left and whether the valve was replaced or repaired. The patient should talk to the doctor about what type of follow-up he/she needs after surgery, and the doctor should know if the patient develops new or worsening signs and symptoms after treatment.

LESS INVASIVE TECHNIQUES:
To treat valve disorders, doctors are developing less invasive techniques, such as replacing or repairing mitral valves using heart catheterization techniques.

Often with the use of robots to help repair the valve, some surgeons now repair the mitral valve through smaller cuts in the chest (minimally invasive cardiac surgery). When having minimally invasive cardiac surgery, people usually have a shorter recovery time and they leave the hospital sooner. To see if this type of surgery might be right for the patient, he/she should talk to the surgeon, as these techniques are not for everyone.

Prognosis:

Not Available

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