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Mitral Regurgitation

(Mitral Insufficiency)

By

Guy P. Armstrong

, MD, Waitemata Cardiology, Auckland Valvular Disorders

Last full review/revision Aug 2021| Content last modified Aug 2021
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Mitral regurgitation is leakage of blood backward through the mitral valve each time the left ventricle contracts.

  • Genetic weakness of the mitral valve tissue (myxomatous degeneration) and heart attack are the most common causes of mitral regurgitation except in places where antibiotics are not readily available to treat streptococcal infections and prevent rheumatic fever.

  • When regurgitation is severe, people may have shortness of breath.

  • Mild regurgitation may not need treatment, but people with more severe regurgitation may need surgery to replace the damaged heart valve.

The mitral valve is in the opening between the left atrium and the left ventricle. The mitral valve opens to allow blood from the left atrium to fill the left ventricle and closes as the left ventricle contracts to pump blood only out into the aorta and not back into the left atrium. When the mitral valve does not close completely, some blood leaks backward into the left atrium, termed regurgitation.

Complications

Mitral valve regurgitation increases the amount of blood (blood volume) and the pressure in the left atrium. The increased blood pressure in the left atrium increases blood pressure in the veins leading from the lungs to the heart (pulmonary veins) and causes the left atrium to enlarge to accommodate the extra blood leaking back from the ventricle. An enlarged atrium often beats rapidly in an irregular pattern (a disorder called atrial fibrillation Atrial Fibrillation and Atrial Flutter Atrial fibrillation and atrial flutter are very fast electrical discharge patterns that make the atria (upper chambers of the heart) contract very rapidly, with some of the electrical impulses... read more ), which reduces the heart's pumping efficiency because the fibrillating atrium is quivering rather than pumping. Consequently, blood does not flow through the atrium briskly, and blood clots may form inside the chamber. If a clot breaks loose (becoming an embolus), it is pumped out of the heart and may block an artery, possibly causing a stroke or other damage.

Severe regurgitation can result in heart failure Heart Failure (HF) Heart failure is a disorder in which the heart is unable to keep up with the demands of the body, leading to reduced blood flow, back-up (congestion) of blood in the veins and lungs, and/or... read more Heart Failure (HF) , in which increased pressure in the atrium causes fluid accumulation (congestion) in the lungs, or in which reduced forward flow of blood from the ventricle to the body deprives organs of the proper amount of blood. The left ventricle may gradually enlarge and weaken, further worsening heart failure.

Causes of Mitral Regurgitation

More often, however, mitral regurgitation develops slowly as a result of gradual deterioration of the valve (caused by mitral valve prolapse Mitral Valve Prolapse (MVP) Mitral valve prolapse is a disorder in which the valve flaps (cusps) bulge into the left atrium when the left ventricle contracts, sometimes allowing leakage (regurgitation) of blood into the... read more Mitral Valve Prolapse (MVP) or rheumatic heart disease) or enlargement of the left ventricle, which pulls the valve apart and prevents it from closing properly. This enlargement is caused by a heart attack or another disorder that weakens the heart muscle (such as a cardiomyopathy Overview of Cardiomyopathy Cardiomyopathy refers to progressive impairment of the structure and function of the muscular walls of the heart chambers. There are three main types of cardiomyopathy: Dilated cardiomyopathy... read more Overview of Cardiomyopathy ).

Rheumatic fever Rheumatic Fever Rheumatic fever is inflammation of the joints, heart, skin, and nervous system, resulting from a complication of untreated streptococcal infection of the throat. This condition is a reaction... read more Rheumatic Fever —a childhood illness that sometimes occurs after untreated strep throat Symptoms Streptococcal infections are caused by any one of several species of Streptococcus. These gram-positive, sphere-shaped (coccal) bacteria (see figure How Bacteria Shape Up) cause many disorders... read more or scarlet fever Symptoms Streptococcal infections are caused by any one of several species of Streptococcus. These gram-positive, sphere-shaped (coccal) bacteria (see figure How Bacteria Shape Up) cause many disorders... read more —used to be the most common cause of mitral regurgitation. But today, rheumatic fever is rare in North America, Western Europe, and other regions where antibiotics are widely used to treat infections such as strep throat. In these regions, rheumatic fever is a common cause of mitral regurgitation only among older people who did not have the benefit of antibiotics during their youth and among people who have moved from regions where antibiotics are not widely used. In such regions, rheumatic fever is still common and still commonly causes mitral stenosis or regurgitation, sometimes 10 years or more after the initial infection. Repeated attacks of rheumatic fever hasten valve deterioration.

Symptoms of Mitral Regurgitation

Diagnosis of Mitral Regurgitation

  • Physical examination

  • Echocardiography

Mitral regurgitation is usually diagnosed based on the characteristics of the heart murmur heard through a stethoscope. The murmur is a distinctive sound produced by blood leaking backward into the left atrium when the left ventricle contracts. The disorder is sometimes diagnosed when a doctor hears this murmur during a routine physical examination.

Doctors then do echocardiography Echocardiography and Other Ultrasound Procedures Ultrasonography uses high-frequency (ultrasound) waves bounced off internal structures to produce a moving image. It uses no x-rays. Ultrasonography of the heart (echocardiography) is one of... read more Echocardiography and Other Ultrasound Procedures , which uses ultrasound waves to produce an image of the heart structures and blood flow. Echocardiography provides the most information about the size of the atrium and ventricle and the amount of blood leaking, so that the severity of the regurgitation can be determined.

Cardiac catheterization Cardiac catheterization Cardiac catheterization and coronary angiography are minimally invasive methods of studying the heart and the blood vessels that supply the heart (coronary arteries) without doing surgery. These... read more Cardiac catheterization is often done when surgery is planned to repair or replace a mitral valve so that doctors can identify coronary artery disease that could also be treated during the heart surgery.

Treatment of Mitral Regurgitation

  • Sometimes valve repair or replacement

If mitral regurgitation is mild, no specific treatment may be required. However, the regurgitation may gradually worsen, so echocardiography is done periodically to help determine whether surgery has become necessary. Surgery must be done before the heart muscle becomes permanently weakened.

When more serious regurgitation causes heart failure in people who cannot undergo surgery, these people are given certain drugs for heart failure, such as spironolactone and carvedilol. People with atrial fibrillation are given anticoagulants such as warfarin.

Surgery may involve

  • Repairing the valve

  • Replacing it with an artificial (prosthetic) valve

Traditional mitral valve repair is done during open heart surgery in which doctors insert a ring that reduces the size of the valve opening. A newer repair technique called percutaneous mitral valve repair (PMVR) is less invasive. In PMVR, the valve is repaired using a clip inserted using catheter passed up to the heart from a vein in the groin (the femoral vein). The clip reduces the size of the valve opening.

Mitral valve replacement with either mechanical or bioprosthetic valves is done via open-heart surgery.

Repairing or replacing the valve (via traditional open-heart surgery) eliminates regurgitation or reduces it enough to make the symptoms tolerable and prevent damage to the heart. When possible, repairing the valve with a ring is preferable to replacing it because a repaired valve usually functions better than a mechanical or bioprosthetic valve and the person does not require lifetime anticoagulation therapy. Percutaneous mitral valve repair (PMVR) is not as effective as the traditional repair or replacement. PMVR is recommended only for patients with severe mitral regurgitation who are too frail for open-heart surgery.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

Drugs Mentioned In This Article

Generic Name Select Brand Names
ALDACTONE
COREG
COUMADIN
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