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Mitral valve regurgitationBy Mayo Clinic staff
Original Article: http://www.mayoclinic.com/health/mitral-valve-regurgitation/DS00421
Mitral valve regurgitation — or mitral regurgitation — happens when your heart's mitral valve doesn't close tightly, which allows blood to flow backward in your heart. When the mitral valve doesn't work properly, blood can't move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath. Mitral valve regurgitation is also called mitral insufficiency or mitral incompetence.
Treatment of mitral valve regurgitation depends on how severe your condition is, whether it's getting worse, and signs and symptoms. For mild cases, treatment may not be necessary. You may need heart surgery to repair or replace the valve for more-severe cases. Left untreated, severe mitral valve regurgitation can cause heart failure or serious heart rhythm problems (arrhythmias).
Signs and symptoms of mitral valve regurgitation depend on its severity and how quickly the condition develops. Mitral valve regurgitation signs and symptoms can include:
- Blood flowing turbulently through your heart (heart murmur)
- Shortness of breath, especially with exertion or when you lie down
- Fatigue, especially during times of increased activity
- Cough, especially at night or when lying down
- Heart palpitations — sensations of a rapid, fluttering heartbeat
- Swollen feet or ankles
- Excessive urination
Mitral valve regurgitation is often mild and progresses slowly. You may have no symptoms for decades and be unaware that you have this condition.
Mitral valve regurgitation is often first suspected when your doctor hears a heart murmur. Sometimes, however, the problem develops quickly, and you may experience a sudden onset of severe signs and symptoms.
When to see a doctor
If you develop signs and symptoms that suggest mitral valve regurgitation or another problem with your heart, see your doctor right away. Sometimes the first signs of mitral valve regurgitation are actually those of its complications, including heart failure. Heart failure is a condition in which your heart can't pump enough blood to the rest of your body, causing shortness of breath, fluid buildup and fatigue. There are a number of causes of this, and mitral valve regurgitation is just one of them.
However, mitral valve regurgitation is usually discovered earlier, during a routine examination when your doctor listens to your heart with a stethoscope. Mitral valve regurgitation can cause an abnormal heart sound (heart murmur).
When mild, mitral valve regurgitation may not progress and may never pose a serious threat to your health. But when severe, mitral valve regurgitation may cause heart complications and may require surgery to correct.
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|Chambers and valves of the heart|
Your heart, which is the pump of your circulatory system, has four chambers. The two upper chambers, the atria, receive blood. The two lower chambers, the ventricles, pump blood.
Blood flows through your heart's chambers, aided by four heart valves. These valves open and close, allowing blood to flow through your heart in only one direction. The mitral valve — which lies between the two left chambers of your heart — has two triangular-shaped flaps of tissue called leaflets.
Heart valves open like a trapdoor. The leaflets of the mitral valve open when the left atrium contracts, forcing blood through the leaflets and into the left ventricle. When the left atrium relaxes between heart contractions, the flaps shut to prevent blood that has just passed into the left ventricle from flowing backward, in the wrong direction.
When working properly, heart valves open and close fully. In mitral valve regurgitation, the mitral valve doesn't close tightly. So, with each heartbeat, some blood from the left ventricle flows backward into the left atrium, instead of forward into the aorta. Regurgitation refers to this backflow of blood through the heart valve.
Causes of mitral valve regurgitation
Mitral valve regurgitation can be caused by many things, including:
- Mitral valve prolapse. Mitral valve prolapse is a condition in which the leaflets and tendon-like cords supporting the mitral valve weaken. The result is that with each contraction of the left ventricle, the valve leaflets bulge (prolapse) up into the left atrium. This common heart defect may prevent the mitral valve from closing tightly and lead to regurgitation. However, mitral valve prolapse is common and most people who have it never develop severe regurgitation.
- Damaged tissue cords. Mitral valve regurgitation may result from damage to the tissue cords that anchor the flaps of the mitral valve to the heart wall. Over time, these cords may stretch or suddenly tear, especially in people with mitral valve prolapse. A tear of these cords can cause substantial leakage through the mitral valve and may require repair by heart surgery.
- Rheumatic fever. Rheumatic fever — a complication of untreated strep throat and once a common childhood illness in the United States — can damage the mitral valve, leading to mitral valve regurgitation later in life. Rheumatic fever can damage the mitral valve in two main ways. The infection may cause the leaflets of the valve to thicken, limiting the valve's ability to open. This causes narrowing of the valve, a condition known as mitral valve stenosis. The infection may also cause scarring of the mitral leaflets, leading to regurgitation. People with rheumatic fever, which is still common in countries where antibiotic use isn't common, may have both mitral valve stenosis and mitral valve regurgitation.
- Endocarditis. The mitral valve may be damaged by endocarditis, an infection of the lining (endocardium) of the heart that can involve heart valves.
- Wear and tear on the valve. The mitral valve opens and shuts tens of thousands of times every day of your life. Sometimes age-related wear and tear on the valve causes mitral valve regurgitation.
- Prior heart attack. A heart attack can damage the area of the heart muscle that supports the mitral valve, affecting the function of the valve. In fact, if the damage is extensive enough, a heart attack may result in sudden and severe mitral valve regurgitation. This sudden onset of regurgitation is sometimes referred to as acute mitral valve regurgitation.
- Untreated high blood pressure. Over time, high blood pressure can cause your heart to work harder, and gradually your heart's left ventricle can enlarge. This can then stretch the tissue around your mitral valve, which can lead to leakage.
- Congenital heart defects. Some babies are born with defects in their hearts, including damaged heart valves.
Severe mitral valve regurgitation — regardless of its cause — can weaken your heart. When the left ventricle contracts in a heart with mitral valve regurgitation, some blood flows backward into the left atrium instead of flowing forward into the aorta. As a result, blood flow to the rest of your body decreases. In response, the left ventricle may enlarge (dilate) so that it can pump more blood with each heartbeat. At first this adaptation helps your heart beat with more force. But eventually, the change weakens your heart and may cause heart failure and heart rhythm irregularities, such as atrial fibrillation.
Several factors can increase your risk of mitral valve regurgitation, including:
- A history of mitral valve prolapse or mitral valve stenosis. However, having either condition doesn't necessarily mean you'll develop mitral valve regurgitation. In fact, most people with mitral valve prolapse never develop severe regurgitation.
- A past heart attack. A heart attack can damage your heart, affecting the function of the mitral valve.
- Use of certain medications. People who take ergotamine and similar medicines for migraines and those who took pergolide (now removed from the market) have an increased risk of mitral regurgitation. Similar problems were noted with the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold.
- Infections such as endocarditis or rheumatic fever. Infections can damage the mitral valve.
- Congenital heart disease. Some people are born with an abnormal mitral valve prone to regurgitation. Often babies born with heart defects may have more than one problem, such as a hole in the upper chambers of the heart (atrial septal defect) and an abnormal mitral valve.
- Age. By middle age, many people have some mitral valve regurgitation caused by natural deterioration of the valve. However, mitral valve regurgitation causes symptoms in only a small percentage of older adults.
When it's mild, mitral valve regurgitation may never cause problems. But when it's severe, mitral valve regurgitation may lead to these complications:
- Heart failure. In heart failure, your heart is unable to pump enough blood to meet your body's needs. Severe mitral regurgitation places an extra strain on the heart due to the need to pump extra blood. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure. Fluid and pressure build up in your lungs as a result of mitral valve regurgitation and can eventually put a strain on the right side of your heart, leading to ankle swelling (edema). People with heart failure experience shortness of breath and fatigue and may wake up at night feeling short of breath.
- Atrial fibrillation. This is an irregular heart rhythm in which your heart's upper chambers (atria) beat chaotically and rapidly. Atrial fibrillation can cause blood clots. These blood clots may break loose from your heart and travel through your bloodstream, often to your brain, causing a stroke. Other irregular heartbeats (heart arrhythmias) also may occur in people with mitral valve regurgitation.
- Endocarditis. Endocarditis is an infection of the inner lining of your heart. Typically the infection involves one of the heart valves, especially if it's already damaged. If the mitral valve is damaged, it's more prone to infection than is a healthy valve. You can develop endocarditis when bacteria from another part of your body spread through the bloodstream and lodge in your heart. Doctors used to recommend that some people with mitral valve regurgitation take antibiotics before certain dental or medical procedures to prevent endocarditis, but antibiotics are no longer considered necessary in most cases for someone with mitral valve regurgitation or mitral valve prolapse.
- Pulmonary hypertension. If you have mitral regurgitation for many years and it's untreated, or treated improperly, you can develop pulmonary hypertension. Pulmonary hypertension is a type of high blood pressure that affects the arteries in the lungs. In mitral regurgitation, your leaky valve may cause increased pressure in the left atrium, which can eventually cause pulmonary hypertension. Pulmonary hypertension in turn causes increased pressure in your right ventricle and atrium, which can lead to heart failure.
Preparing for your appointment
If you think you have mitral valve regurgitation, make an appointment to see your doctor. Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do
- Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance.
- Write down any symptoms you're experiencing, including any that may seem unrelated to mitral valve regurgitation.
- Write down key personal information, including a family history of heart disease, heart defects, genetic disorders, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
- Make a list of all medications, as well as any vitamins or supplements, that you're taking.
- Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Be prepared to discuss your diet and exercise habits. If you don't already follow a diet or exercise routine, be ready to talk to your doctor about any challenges you might face in getting started.
- Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important, in case time runs out. For mitral valve regurgitation, some basic questions to ask your doctor include:
- What is likely causing my symptoms or condition?
- What are other possible causes for my symptoms or condition?
- What kinds of tests will I need?
- What's the best treatment?
- What are the alternatives to the primary approach that you're suggesting?
- I have other health conditions. How can I best manage them together?
- Are there any restrictions that I need to follow?
- Should I see a specialist?
- If I need surgery, which surgeon do you recommend for mitral valve repair?
- Is there a generic alternative to the medicine you're prescribing for me?
- Are there any brochures or other printed material that I can take home with me? What websites do you recommend?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
- When did you first begin experiencing symptoms?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
Tests and diagnosis
If you have signs and symptoms of mitral valve regurgitation, you may need several diagnostic tests. But first your doctor will ask you about your general health, including your symptoms, prior tests and history of heart disease in your family.
Next, your doctor performs a physical examination. He or she listens to your heart sounds with a stethoscope. Mitral valve regurgitation usually produces a heart murmur. The murmur is the sound of blood leaking backward through the mitral valve.
With this information, your doctor decides which tests to request so that he or she can make a diagnosis and develop a treatment plan. You may be referred to a cardiologist — a doctor who specializes in the study of the heart and its function. Common tests used to diagnose heart valve problems include:
- Echocardiogram. This test uses sound waves to produce an image of your heart. In an echocardiogram, sound waves are directed at your heart from a wand-like device (transducer) held on your chest. An echocardiogram helps your doctor get a close look at the mitral valve and how well it is — or isn't — working.
- Chest X-ray. With an X-ray of your chest, your doctor can see the size and shape of your heart to determine whether the left ventricle is enlarged. A chest X-ray also allows your doctor to evaluate your lungs. Mitral valve regurgitation may result in blood backing up into your lungs, which causes congestion that's visible on an X-ray.
- Electrocardiogram (ECG). In this test, adhesive patches with wires (electrodes) are attached to your skin to measure the electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed on paper. An ECG gives information about heart rhythm and, indirectly, heart size. With mitral valve regurgitation, the left ventricle may be enlarged and you may have heart rhythm irregularities (arrhythmias).
- Holter monitor. A Holter monitor is a portable device that you wear to record a continuous ECG, usually for 24 to 72 hours. Holter monitoring is used to detect intermittent heart rhythm irregularities that may be associated with mitral valve regurgitation.
- Transesophageal echocardiogram. This type of echocardiogram allows an even closer look at the mitral valve. The esophagus, the tube that runs from your throat to your stomach, lies close to your heart. In a transesophageal echocardiogram, a small transducer attached to the end of a tube is inserted down the esophagus. Because the esophagus lies close to your mitral valve, having the transducer there provides a clearer picture of valve structure and blood flow through it.
- Exercise tests. Various exercise tests can help measure your tolerance for activity and check your heart's response to exertion (exercise).
- Cardiac catheterization. In this procedure, a doctor threads a thin tube (catheter) through a blood vessel in your arm or groin into your heart. The catheter is used to deliver dye into the heart chambers and the blood vessels of your heart. The dye, appearing on X-ray images as it moves through your heart, gives your doctors detailed information about your heart and heart valves. Some catheters used in cardiac catheterization have miniature devices (sensors) at the tips that can measure pressure within heart chambers, such as the left ventricle.
Treatments and drugs
Mitral valve regurgitation treatment depends on how severe your condition is, and if it's getting worse. The goal of treatment is to improve your heart's function while minimizing your signs and symptoms and avoiding future complications.
Some people, especially those with mild regurgitation, don't need to be treated. However, even if you don't have signs and symptoms with mitral valve regurgitation, the condition may require monitoring by your doctor. You may need regular evaluations, with the frequency depending on the amount of regurgitation.
Observation isn't the same as ignoring the condition. Working with your doctor, you should keep a close eye on your symptoms in case you do end up needing treatment.
Medication can't correct a deformity of a mitral valve. But medications such as diuretics are available to relieve fluid accumulation in your lungs or legs, which can accompany mitral valve regurgitation. High blood pressure makes mitral valve regurgitation worse, so if you have high blood pressure, your doctor may prescribe medication to help lower it. Following a low-salt diet helps prevent fluid buildup and helps control blood pressure.
Your mitral valve may need to be surgically repaired or replaced. If you feel good, you may question the need for open-heart surgery. But you can have bad mitral valve regurgitation and yet feel good. This is because the heart is good at counteracting problems caused by a leaky mitral valve.
However, if you wait too long to have surgery, your heart might become damaged beyond repair or become so weakened that surgery wouldn't help. That's why it's important to closely monitor mitral valve regurgitation and get surgery if your doctor feels it will help you avoid future problems.
Discuss the risks and benefits of surgery with your doctor. Your surgery options include:
Valve repair. Mitral valve repair is a surgery that preserves your own valve. For most people with mitral valve prolapse, this is the preferred surgical treatment to correct your condition.
Your mitral valve consists of two triangular-shaped flaps of tissue called leaflets. The leaflets of the mitral valve connect to the heart muscle through a ring called the annulus. The surgeon can modify the original valve (valvuloplasty) to eliminate backward blood flow. Surgeons can also repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly. Sometimes repairing the valve includes tightening or replacing the ring around the valve (annulus). This is called an annuloplasty. It's important to have an experienced surgeon perform mitral valve repair.
Valve replacement. Valve replacement is done when valve repair isn't possible. In valve replacement surgery, the damaged mitral valve is replaced by an artificial (prosthetic) valve. The two types of artificial valves are mechanical and tissue.
Mechanical valves, which are made of metal, may last a long time. However, if you have a mechanical valve, you must use an anticoagulant medication, such as warfarin (Coumadin), for the rest of your life to prevent blood clots from forming on the valve. If a blood clot forms on the valve and breaks free, it could travel to your brain and cause a stroke.
Tissue valves are made from animal tissue such as a pig's heart valve. These kinds of valves are called bioprostheses. They may wear out over time and need replacement. However, an advantage of the tissue valve is that you don't have to use long-term anticoagulant medication.
Mitral valve repair or replacement requires open-heart surgery under general anesthesia. With traditional open-heart surgery, a cut that's the length of your breastbone (sternum) is made and your heart is exposed and connected to a heart-lung machine that assumes your breathing and blood circulation functions during the procedure. Your surgeon then replaces or repairs the valve. After the operation, you'll spend one or more days in an intensive care unit, where your heart function and general recovery will be closely monitored.
Mitral valve regurgitation can be eliminated with surgery, but some people may continue to have some leakage. How well you do depends on whether the valve was repaired or replaced, how much regurgitation is left, and your heart's pumping function. Talk to your doctor about what type of follow-up you need after surgery, and let your doctor know if you develop new or worsening signs and symptoms after treatment.
Less invasive techniques
Doctors are developing less invasive techniques to treat valve disorders, such as repairing or replacing mitral valves using heart catheterization or robotic techniques.
Some surgeons now repair the mitral valve through smaller cuts in your chest (minimally invasive cardiac surgery). People who have minimally invasive cardiac surgery usually have a shorter recovery time and leave the hospital sooner. These techniques are not for everyone, so talk to your surgeon to see if this type of surgery might be right for you.
Lifestyle and home remedies
To improve your quality of life if you have mitral valve regurgitation, your doctor may recommend that you:
- Check your blood pressure regularly. Control of high blood pressure is important if you have mitral valve regurgitation.
- Eat a heart-healthy diet. Food doesn't directly affect mitral valve regurgitation. However, developing coronary artery disease — blockages of arteries that feed your heart muscle — may lead to heart attacks with further weakening of the heart muscle. To follow a heart-healthy diet, eat low-fat foods and check your cholesterol levels regularly. Also, your doctor may suggest that you limit your salt intake. If you have any questions about your diet, ask to talk to a dietitian.
- Maintain a healthy weight. Excess weight may make you short of breath and may complicate heart surgery if you ever need it. Keep your weight within a range recommended by your doctor.
- Cut back on caffeine. Irregular heartbeats (arrhythmias) may occur in people with mitral valve regurgitation. Arrhythmias may worsen if you have too much caffeine. Ask your doctor about drinking beverages with caffeine, such as coffee and soft drinks.
- Cut back on alcohol. Heavy alcohol use can cause arrhythmias and can make your symptoms worse. Excessive alcohol use can also cause cardiomyopathy, a condition of weakened heart muscle that often leads to mitral regurgitation. If you have mitral valve regurgitation, ask your doctor about the effects of drinking alcohol.
- Exercise. Physical activity helps to keep your body fit and may also help you to recover faster if you ever need heart surgery. Your doctor usually gives you guidelines for your exercise program. Don't stop exercising if you've received a diagnosis of mitral valve regurgitation. If you find that you're unable to do things because of mitral valve regurgitation, talk to your doctor.
- See your doctor regularly. Establish a regular evaluation schedule with your cardiologist or primary care provider.
If you're a woman with mitral valve regurgitation, discuss family planning with your doctor before you become pregnant, because your heart works harder during pregnancy. How a heart with mitral valve regurgitation tolerates this extra work depends on the degree of regurgitation and how well your heart pumps. Should you become pregnant, your cardiologist and obstetrician need to evaluate you throughout your pregnancy, labor and delivery, and after delivery.
Because rheumatic fever is a risk factor for developing mitral valve regurgitation, if you have a severe sore throat you should see a doctor. Untreated strep throat can lead to rheumatic fever. Fortunately, strep throat is easily treated with antibiotics.
If you have high blood pressure, it's important to make sure it's well controlled to prevent mitral regurgitation.
If you have an abnormal valve, such as mitral valve prolapse, it's important to seek medical care if you develop a fever or signs or symptoms of an infection of your heart tissue (endocarditis).
If you have mitral valve regurgitation, talk to your doctor about the frequency of follow-up examinations, and have your doctor regularly check the amount of regurgitation through regular physical examinations and follow-up echocardiograms when needed.
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