|
|
| Line 1: |
Line 1: |
| {{see also|aortic insufficiency|tricuspid insufficiency}}
| | 46 years old Jeweller Courtney from Drumheller, likes to spend time photography, [http://bigstageworld.com/groups/riverbank-fernvale/ private property developers in singapore] developers in singapore and tombstone rubbing. that included taking a trip to Hazor. |
| {{Infobox disease |
| |
| Name = Mitral regurgitation |
| |
| ICD10 = {{ICD10|I|05|1|i|05}}, {{ICD10|I|34|0|i|30}}, {{ICD10|Q|23|3|q|20}} |
| |
| ICD9 = {{ICD9|394.1}}, {{ICD9|424.0}}, {{ICD9|746.6}} |
| |
| ICDO = |
| |
| Image = Mitral Regurgitation scheme1.png |
| |
| Caption = '''Mitral regurgitation (schematic drawing)'''<br/>During systole, contraction of the left ventricle causes abnormal backflow (arrow) into the left atrium.<br/>1 Mitral valve<br/>2 Left Ventricle<br/>3 Left Atrium<br/>4 [[Aorta]] |
| |
| OMIM = |
| |
| OMIM_mult = |
| |
| MedlinePlus = 000176 |
| |
| eMedicineSubj = emerg |
| |
| eMedicineTopic = 314 |
| |
| DiseasesDB = 8275 |
| |
| MeshID = D008944 |
| |
| }}
| |
| '''Mitral regurgitation''' ('''MR'''), '''mitral insufficiency''' or '''mitral incompetence''' is a disorder of the [[heart]] in which the [[mitral valve]] does not close properly when the heart pumps out [[blood]]. It is the abnormal leaking of blood from the [[left ventricle]], through the mitral valve, and into the [[left atrium]], when the left ventricle contracts, i.e. there is [[Regurgitation (circulation)|regurgitation]] of blood back into the left atrium.<ref>[http://www.mountsinai.org/Other/Diseases/Mitral%20valve%20regurgitation Mitral valve regurgitation] at [[Mount Sinai Hospital, New York|Mount Sinai Hospital]]</ref> MR is the most common form of [[valvular heart disease]].<ref name='MedlineMitChron2008'>{{cite encyclopedia |last=Weinrauch |first=LA |author= |authorlink= |coauthors= |editor= |encyclopedia=Medline Plus Encyclopedia |title=Mitral regurgitation - chronic |url=http://www.nlm.nih.gov/medlineplus/ency/article/000176.htm |accessdate=2009-12-04 |edition= |date=2008-05-12 |year= |publisher=U.S. National Library of Medicine and National Institutes of Health |volume= |location= |id= |doi= |pages= |quote= }}</ref>
| |
| | |
| ==Symptoms and signs==
| |
| [[File:Phonocardiograms from normal and abnormal heart sounds.png|thumb|Phonocardiograms from normal and abnormal heart sounds]]
| |
| The symptoms associated with mitral regurgitation are dependent on which phase of the disease process the individual is in. Individuals with acute mitral regurgitation will have the signs and symptoms of decompensated [[congestive heart failure]] (i.e. [[shortness of breath]], [[pulmonary edema]], [[orthopnea]], and [[paroxysmal nocturnal dyspnea]]<ref name=agabegi2nd-ch1/>), as well as symptoms suggestive of a low cardiac output state (i.e. decreased exercise tolerance). [[Palpitations]] are also common.<ref name=agabegi2nd-ch1/> Cardiovascular collapse with [[Shock (circulatory)|shock]] ([[cardiogenic shock]]) may be seen in individuals with acute mitral regurgitation due to [[papillary muscle]] rupture or rupture of a [[chordae tendineae|chorda tendinea]].
| |
| | |
| Individuals with chronic compensated mitral regurgitation may be asymptomatic, with a normal exercise tolerance and no evidence of heart failure. These individuals may be sensitive to small shifts in their intravascular volume status, and are prone to develop volume overload ([[congestive heart failure]]).
| |
| | |
| Findings on clinical examination depend on the severity and duration of mitral regurgitation. The mitral component of the [[first heart sound]] is usually soft and with a laterally displaced apex beat,<ref name=agabegi2nd-ch1/> often with [[Parasternal heave|heave]].<ref name=uas/> The first heart sound is followed by a high-pitched '''[[holosystolic murmur]]''' at the apex, radiating to the back or clavicular area.<ref name=agabegi2nd-ch1/> Its duration is, as the name suggests, the whole of systole. The loudness of the murmur does not correlate well with the severity of regurgitation. It may be followed by a loud, palpable [[P2 beat|P<sub>2</sub>]],<ref name=agabegi2nd-ch1/> heard best when lying on the left side.<ref name=uas/> A [[third heart sound]] is commonly heard.<ref name=agabegi2nd-ch1/>
| |
| | |
| Commonly, [[atrial fibrillation]] is found.<ref name=agabegi2nd-ch1/>
| |
| | |
| In acute cases, the murmur and [[tachycardia]] may be only distinctive signs.<ref name=uas/>
| |
| | |
| Patients with [[mitral valve prolapse]] often have a mid-to-late systolic click and a late systolic murmur.
| |
| | |
| ==Cause==
| |
| The mitral valve comprises two valve leaflets: the mitral valve [[Fibrous rings of heart|annulus]] which forms a ring around the valve leaflets, and the [[papillary muscles]] which tether the valve leaflets to the left ventricle and prevent them from [[mitral valve prolapse|prolapsing]] into the left atrium. The ''[[chordae tendineae]]'' are also present and connect the valve leaflets to the papillary muscles. A dysfunction of any of these portions of the mitral valve apparatus can cause mitral regurgitation.
| |
| | |
| The most common cause of mitral regurgitation is [[mitral valve prolapse]] (MVP). Mitral valve prolapse is in turn is caused by [[myxomatous degeneration]],<ref name='MedicineNetMVP-Kulick'>{{cite web|url=http://www.medicinenet.com/mitral_valve_prolapse/article.htm |title=Mitral Valve Prolapse (MVP) |accessdate=2010-01-18 |last=Kulick |first=Daniel |work=MedicineNet.com |publisher=MedicineNet, Inc }}</ref> and is the most common cause of primary mitral regurgitation in the [[United States]], causing about 50% of primary mitral regurgitation. Myxomatous degeneration of the mitral valve is more common in women as well as with advancing age which causes a stretching of the leaflets of the valve and the chordae tendineae. Such elongation prevent the valve leaflets from fully coming together when the valve closes, causing the valve leaflets to prolapse into the left atrium, thereby causing mitral regurgitation.
| |
| | |
| [[Ischemic heart disease]] causes mitral regurgitation by the combination of ischemic dysfunction of the papillary muscles, and the dilatation of the left ventricle. This can lead to the subsequent displacement of the papillary muscles and the dilatation of the mitral valve annulus.
| |
| | |
| [[Rheumatic fever]] and [[Marfan's syndrome]] are other typical causes of mitral regurgitation.<ref name=agabegi2nd-ch1/> Mitral regurgitation and mitral valve prolapse are also common in [[Ehlers Danlos Syndrome]]. <ref>[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002439] NIH US National Library of Medicine, A.D.A.M. Medical Encyclopedia, Ehlers Danlos Syndrome- PMH0002439 </ref>
| |
| | |
| '''Secondary mitral regurgitation''' is due to the dilatation of the [[left ventricle]] that causes stretching of the mitral valve annulus and displacement of the papillary muscles. This dilatation of the left ventricle can be due to any cause of [[dilated cardiomyopathy]] including [[aortic insufficiency]], nonischemic dilated [[cardiomyopathy]], and [[Noncompaction Cardiomyopathy]]. Because the papillary muscles, chordae, and valve leaflets are usually normal in such conditions, it is also called '''functional mitral regurgitation'''.<ref>[http://www.uptodate.com/patients/content/topic.do?topicKey=~Ux3kbGWsXmiaqiH Functional mitral regurgitation] By William H Gaasch, MD. Retrieved on Jul 8, 2010</ref>
| |
| | |
| Acute mitral regurgitation is most often caused by [[endocarditis]], mainly ''[[Staphylococcus aureus|S. aureus]]''.<ref name=agabegi2nd-ch1>{{cite book |author=Elizabeth D Agabegi; Agabegi, Steven S. |title=Step-Up to Medicine (Step-Up Series) |publisher=Lippincott Williams & Wilkins |location=Hagerstwon, MD |year=2008 |pages= |isbn=0-7817-7153-6 |oclc= |doi= |accessdate=}} Chapter 1: Diseases of the Cardiovascular system > Section: Valvular Heart Disease</ref> Rupture or dysfunction of the [[papillary muscle]] are also common causes in acute cases,<ref name=agabegi2nd-ch1/> dysfunction which can include mitral valve prolapse.<ref name=uas>VOC=VITIUM ORGANICUM CORDIS, a compendium of the Department of Cardiology at Uppsala Academic Hospital. By Per Kvidal September 1999, with revision by Erik Björklund May 2008</ref>
| |
| | |
| ==Pathophysiology==
| |
| The pathophysiology of mitral regurgitation can be broken into three phases of the disease process: the acute phase, the chronic compensated phase, and the chronic decompensated phase.<ref name='eMedMR2009'>{{cite encyclopedia |last=Di Sandro |first=D |encyclopedia=eMedicine |title=Mitral Regurgitation |url=http://emedicine.medscape.com/article/758816-overview |accessdate=2009-12-08 |date=2009-06-08 |publisher=Medscape}}</ref>
| |
| | |
| ===Acute phase===
| |
| Acute mitral regurgitation (as may occur due to the sudden rupture of a chorda tendinae or papillary muscle) causes a sudden volume overload of both the left atrium and the left ventricle. The left ventricle develops volume overload because with every contraction it now has to pump out not only the volume of blood that goes into the [[aorta]] (the forward [[cardiac output]] or forward stroke volume), but also the blood that regurgitates into the left atrium (the regurgitant volume). The combination of the forward stroke volume and the regurgitant volume is known as the total stroke volume of the left ventricle.
| |
| | |
| In the acute setting, the stroke volume of the left ventricle is increased (increased [[ejection fraction]]), this happens because of more complete emptying of heart. However, as it progresses the LV volume increases and the contractile function deteriorates and thus leading to dysfunctional LV and a decrease in ejection fraction.<ref>Harrison's Internal Medicine 17th edition</ref> The increase in stroke volume is explained by the [[Frank–Starling mechanism]], in which increased ventricular pre-load stretches the myocardium such that contractions are more forceful.
| |
| | |
| The regurgitant volume causes a volume overload and a pressure overload of the left atrium. The increased pressures in the left atrium inhibit drainage of blood from the lungs via the pulmonary veins. This causes [[congestive heart failure|pulmonary congestion]].
| |
| | |
| ===Chronic phase===
| |
| ====Compensated====
| |
| If the mitral regurgitation develops slowly over months to years or if the acute phase cannot be managed with medical therapy, the individual will enter the chronic compensated phase of the disease. In this phase, the left ventricle develops eccentric hypertrophy in order to better manage the larger than normal stroke volume. The eccentric hypertrophy and the increased diastolic volume combine to increase the stroke volume (to levels well above normal) so that the forward stroke volume (forward cardiac output) approaches the normal levels.
| |
| | |
| In the left atrium, the volume overload causes enlargement of the chamber of the left atrium, allowing the filling pressure in the left atrium to decrease. This improves the drainage from the pulmonary veins, and signs and symptoms of pulmonary congestion will decrease.
| |
| | |
| These changes in the left ventricle and left atrium improve the low forward cardiac output state and the pulmonary congestion that occur in the acute phase of the disease. Individuals in the chronic compensated phase may be asymptomatic and have normal exercise tolerances.
| |
| | |
| ====Decompensated====
| |
| An individual may be in the compensated phase of mitral regurgitation for years, but will eventually develop left ventricular dysfunction, the hallmark for the chronic decompensated phase of mitral regurgitation. It is currently unclear what causes an individual to enter the decompensated phase of this disease. However, the decompensated phase is characterized by calcium overload within the cardiac [[myocyte]]s.
| |
| | |
| In this phase, the ventricular myocardium is no longer able to contract adequately to compensate for the volume overload of mitral regurgitation, and the stroke volume of the left ventricle will decrease. The decreased stroke volume causes a decreased forward cardiac output and an increase in the [[Systole (medicine)|end-systolic]] volume. The increased end-systolic volume translates to increased filling pressures of the left ventricle and increased pulmonary venous congestion. The individual may again have symptoms of congestive heart failure.
| |
| | |
| The left ventricle begins to dilate during this phase. This causes a dilatation of the mitral valve annulus, which may worsen the degree of mitral regurgitation. The dilated left ventricle causes an increase in the wall stress of the cardiac chamber as well.
| |
| | |
| While the [[ejection fraction]] is less in the chronic decompensated phase than in the acute phase or the chronic compensated phase of mitral regurgitation, it may still be in the normal range (i.e.: > 50 percent), and may not decrease until late in the disease course. A decreased ejection fraction in an individual with mitral regurgitation and no other cardiac abnormality should alert the physician that the disease may be in its decompensated phase.
| |
| | |
| ==Diagnosis==
| |
| There are many diagnostic tests that have abnormal results in the presence of mitral regurgitation. These tests suggest the diagnosis of mitral regurgitation and may indicate to the physician that further testing is warranted. For instance, the [[electrocardiogram]] (ECG) in long standing mitral regurgitation may show evidence of left atrial enlargement and [[left ventricular hypertrophy]]. [[Atrial fibrillation]] may also be noted on the ECG in individuals with chronic mitral regurgitation. The ECG may not show any of these finding in the setting of acute mitral regurgitation.
| |
| {| class="wikitable"
| |
| |+ Comparison of acute and chronic phases of mitral regurgitation
| |
| |-
| |
| !
| |
| ! scope="col" | Acute
| |
| ! scope="col" | Chronic
| |
| |-
| |
| ! scope="row" | [[Electrocardiogram]]
| |
| | Normal
| |
| | P mitrale, [[Atrial fibrillation]], [[left ventricular hypertrophy]]
| |
| |-
| |
| ! scope="row" | Heart size
| |
| | Normal
| |
| | Cardiomegaly, left atrial enlargement
| |
| |-
| |
| ! scope="row" | [[Heart sounds|Systolic murmur]]
| |
| | Heard at the base, radiates to the neck, spine, or top of head
| |
| | Heard at the apex, radiates to the axilla
| |
| |-
| |
| ! scope="row" | Apical thrill
| |
| | May be absent
| |
| | Present
| |
| |-
| |
| ! scope="row" | [[Jugular venous pressure|Jugular venous distension]]
| |
| | Present
| |
| | Absent
| |
| |}
| |
| | |
| The quantification of mitral regurgitation usually employs imaging studies such as echocardiography or magnetic resonance angiography of the heart.
| |
| | |
| ===Chest x-ray===
| |
| The chest [[x-ray]] in individuals with chronic mitral regurgitation is characterized by enlargement of the left atrium and the left ventricle.<ref name=agabegi2nd-ch1/> The pulmonary vascular markings are typically normal, since pulmonary venous pressures are usually not significantly elevated.
| |
| | |
| ===Echocardiography===
| |
| [[File:Mitralinsuff TEE.jpg|right|thumb|400px|transesophageal echocardiogram of mitral valve prolapse]]
| |
| The [[echocardiogram]] is commonly used to confirm the diagnosis of mitral regurgitation. Color doppler flow on the transthoracic echocardiogram (TTE) will reveal a jet of blood flowing from the left ventricle into the left atrium during ventricular [[Systole (medicine)|systole]]. Also, it may detect a dilated left atrium and ventricle and decreased left ventricular function.<ref name=agabegi2nd-ch1/>
| |
| | |
| Because of the inability in getting accurate images of the left atrium and the pulmonary veins on the transthoracic echocardiogram, a [[transesophageal echocardiogram]] may be necessary to determine the severity of the mitral regurgitation in some cases.
| |
| | |
| Factors that suggest severe mitral regurgitation on echocardiography include systolic reversal of flow in the pulmonary veins and filling of the entire left atrial cavity by the regurgitant jet of MR.
| |
| | |
| ===Electrocardiography===
| |
| ''P mitrale'' is broad, notched P waves in several or many leads with a prominent late negative component to the P wave in lead V<sub>1</sub>, and may be seen in mitral regurgitation, but also in [[mitral stenosis]], and, potentially, any cause of overload of the left atrium.<ref name=stedmans>[http://www.medilexicon.com/medicaldictionary.php?t=70229 medilexicon.com < P mitrale] Citing. Stedman's Medical Dictionary. Copyright 2006</ref> Thus, ''P-sinistrocardiale'' may be a more appropriate term.<ref name=stedmans/>
| |
| | |
| ===Quantification of mitral regurgitation===
| |
| The degree of severity of mitral regurgitation can be quantified by the [[regurgitant fraction]], which is the percentage of the left ventricular stroke volume that regurgitates into the left atrium.
| |
| | |
| :regurgitant fraction = <math>\frac{V_{mitral} - V_{aortic}} {V_{mitral}} \times 100%</math>
| |
| | |
| where V<sub>mitral</sub> and V<sub>aortic</sub> are respectively the volumes of blood that flow forward through the mitral valve and aortic valve during a [[cardiac cycle]].
| |
| Methods that have been used to assess the regurgitant fraction in mitral regurgitation include echocardiography, cardiac catheterization, fast CT scan, and cardiac MRI.
| |
| | |
| The echocardiographic technique to measure the regurgitant fraction is to determine the forward flow through the mitral valve (from the left atrium to the left ventricle) during ventricular [[diastole]], and comparing it with the flow out of the left ventricle through the aortic valve in ventricular [[Systole (medicine)|systole]]. This method assumes that the aortic valve does not suffer from [[aortic insufficiency]].
| |
| | |
| Another way to quantify the degree of mitral regurgitation is to determine the area of the regurgitant flow at the level of the valve. This is known as the regurgitant orifice area, and correlates with the size of the defect in the mitral valve. One particular echocardiographic technique used to measure the orifice area is measurement of the [[proximal isovelocity surface area]] (PISA). The flaw of using PISA to determine the mitral valve regurgitant orifice area is that it measures the flow at one moment in time in the [[cardiac cycle]], which may not reflect the average performance of the regurgitant jet.
| |
| | |
| <table border="1" cellpadding="5" cellspacing="0" align="center">
| |
| <caption>'''Determination of the degree of mitral regurgitation'''</caption>
| |
| <tr>
| |
| <th style="background:#efefef;">Degree of mitral regurgitation</th>
| |
| <th style="background:#efefef;">Regurgitant fraction</th>
| |
| <th style="background:#efefef;" width="100px">Regurgitant Orifice area</th>
| |
| </tr>
| |
| <tr><td>Mild mitral regurgitation</td><td>< 20 percent</td></tr>
| |
| <tr><td>Moderate mitral regurgitation</td><td>20 - 40 percent</td></tr>
| |
| <tr><td>Moderate to severe mitral regurgitation</td><td>40 - 60 percent</td></tr>
| |
| <tr><td>Severe mitral regurgitation</td><td>> 60 percent</td><td>> 0.4 cm<sup>2</sup></td></tr>
| |
| </table>
| |
| | |
| ==Treatment==
| |
| The treatment of mitral regurgitation depends on the acuteness of the disease and whether there are associated signs of hemodynamic compromise.
| |
| | |
| In acute mitral regurgitation secondary to a mechanical defect in the heart (i.e. rupture of a papillary muscle or chordae tendineae), the treatment of choice is mitral valve surgery. If the patient is hypotensive prior to the surgical procedure, an [[intra-aortic balloon pump]] may be placed in order to improve perfusion of the organs and to decrease the degree of mitral regurgitation.<ref name=agabegi2nd-ch1/>
| |
| | |
| If the individual with acute mitral regurgitation is normotensive, vasodilators may be of use to decrease the [[afterload]] seen by the left ventricle and thereby decrease the regurgitant fraction. The vasodilator most commonly used is [[nitroprusside]].
| |
| | |
| Individuals with chronic mitral regurgitation can be treated with vasodilators as well to decrease afterload.<ref name=agabegi2nd-ch1/> In the chronic state, the most commonly used agents are [[ACE inhibitor]]s and [[hydralazine]]. Studies have shown that the use of ACE inhibitors and hydralazine can delay surgical treatment of mitral regurgitation.<ref>{{cite journal |author=Greenberg BH, Massie BM, Brundage BH, Botvinick EH, Parmley WW, Chatterjee K |title=Beneficial effects of hydralazine in severe mitral regurgitation |journal=Circulation |volume=58 |issue=2 |pages=273–9 |year=1978 |pmid=668075 |doi= |url=}}</ref><ref>{{cite journal |author=Hoit BD |title=Medical treatment of valvular heart disease |journal=Curr. Opin. Cardiol. |volume=6 |issue=2 |pages=207–11 |year=1991 |pmid=10149580 |doi= 10.1097/00001573-199104000-00005|url=}}</ref> The current guidelines for treatment of mitral regurgitation limit the use of vasodilators to individuals with [[hypertension]], however. Any hypertension is treated aggressively,<ref name=uas/> e.g. by [[diuretics]] and a [[low sodium diet]].<ref name=agabegi2nd-ch1/> In both hypertensive and normotensive cases, [[digoxin]] and [[antiarrhythmic]]s are also indicated.<ref name=agabegi2nd-ch1/><ref name=uas/> Also, chronic [[anticoagulation]] is given where there is concomitant [[mitral valve prolapse]]<ref name=uas/> or [[atrial fibrillation]].<ref name=agabegi2nd-ch1/> Medical therapy is non-curative and is generally used for mild-to-moderate regurgitation or in patients who cannot tolerate surgery.
| |
| | |
| Surgery is curative of mitral valve regurgitation. There are two surgical options for the treatment of mitral regurgitation: [[mitral valve replacement]] and [[mitral valve repair]].<ref name=agabegi2nd-ch1/> Mitral valve repair is preferred to mitral valve replacement where a repair is feasible as bioprosthetic replacement valves have a limited lifespan of 10 to 15 years, whereas synthetic replacement valves require ongoing use of blood thinners to reduce the risk of stroke. There are two general categories of approaches to mitral valve repair: Resection of the prolapsed valvular segment (sometimes referred to as the 'Carpentier' approach), and installation of artificial chordae to "anchor" the prolapsed segment to the papillary muscle (sometimes referred to as the 'David' approach). With the resection approach, any prolapsing tissue is resected, in effect removing the hole through which the blood is leaking. In the artificial chordae approach, ePTFE (expanded polytetrafluoroethylene, or Gore-Tex™ sutures are used to replace the broken or stretched chordae tendonae, bringing the natural tissue back into the physiological position, thus restoring the natural anatomy of the valve. With both techniques, an annuloplasty ring is typically secured to the annulus, or opening of the mitral valve, to provide additional structural support. In some cases, the "double orifice" (or 'Alfieri') technique for mitral valve repair, the opening of the mitral valve is sewn closed in the middle, leaving the two ends still able to open. This ensures that the mitral valve closes when the left ventricle pumps blood, yet allows the mitral valve to open at the two ends to fill the left ventricle with blood before it pumps. Mitral valve surgery generally requires "open-heart" surgery in which the heart is arrested and the patient is placed on a heart-lung machine (cardiopulmonary bypass). This allows the complex surgery to proceed in a still environment.
| |
| | |
| Due to the physiological stress associated with open-heart surgery, elderly and very sick patients may be subject to increased risk, and may not be candidates for this type of surgery. As a consequence, there are attempts to identify means of correcting mitral regurgitation on a beating heart. The Alfieri technique for instance, has been replicated using a percutaneous [[catheter]] technique which installs a clip to hold the middle of the mitral valve closed.<ref name='Tirrell2010'>{{cite news | first=Meg | last=Tirrell | coauthors= |authorlink= | title=Abbott MitraClip Offers Safe Alternative to Open-Heart Surgery | date=2010-03-14 | publisher=Bloomberg L.P | url =http://www.businessweek.com/news/2010-03-14/abbott-mitraclip-offers-safe-alternative-to-open-heart-surgery.html | work =Bloomberg Business Week | pages = | accessdate = 2010-03-14 | language = }}</ref><ref>{{cite journal |author=Garg P, Walton AS |title=The new world of cardiac interventions: a brief review of the recent advances in non-coronary percutaneous interventions |journal=Heart Lung Circ |volume=17 |issue=3 |pages=186–99 |date=June 2008 |pmid=18262841 |doi=10.1016/j.hlc.2007.10.019 |url=}}</ref><ref>{{cite journal|last=Feldman M.D.|first=Ted|coauthors=Elyse Foster, M.D., Donald G. Glower, M.D., Saibal Kar, M.D., Michael J. Rinaldi, M.D., Peter S. Fail, M.D., Richard W. Smalling, M.D., Ph.D., Robert Siegel, M.D., Geoffrey A. Rose, M.D., Eric Engeron, M.D., Catalin Loghin, M.D., Alfredo Trento, M.D., Eric R. Skipper, M.D., Tommy Fudge, M.D., George V. Letsou, M.D., Joseph M. Massaro, Ph.D., and Laura Mauri, M.D. for the EVEREST II Investigators|title=Percutaneous Repair or Surgery for Mitral Regurgitation|journal=New England Journal of Medicine|date=14 April 2011|volume=364|pages=1395–1406|url=http://www.nejm.org/doi/full/10.1056/NEJMoa1009355?query=featured_home|doi=10.1056/NEJMoa1009355}}</ref>
| |
| | |
| ===Surgery===
| |
| Indications for surgery for chronic mitral regurgitation include signs of left ventricular dysfunction with ejection fraction less than 60%, severe pulmonary hypertension with pulmonary artery systolic pressure greater than 50mmHg at rest or 60mmHg during activity, and new onset [[atrial fibrillation]].
| |
| <table border="1" cellpadding="5" cellspacing="0" align="center">
| |
| <caption>'''Indications for surgery for chronic mitral regurgitation'''<ref>{{cite journal |author= Bonow R, et al|title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. |journal=Circulation |volume=118 |issue=15 |pages=e523 |year=2008|pmid=18820172 |doi= 10.1161/CIRCULATIONAHA.108.190748|url=}}</ref></caption>
| |
| <tr>
| |
| <th style="background:#efefef;">Symptoms</th>
| |
| <th style="background:#efefef;">LV EF</th>
| |
| <th style="background:#efefef;">LVESD</th>
| |
| </tr>
| |
| <tr><td>[[New York Heart Association Functional Classification|NYHA II]]</td><td>> 30 percent</td><td>< 55 mm</td></tr>
| |
| <tr><td>NYHA III-IV</td><td>< 30 percent</td><td>> 55 mm</td></tr>
| |
| <tr><td>Asymptomatic</td><td>30 - 60 percent</td><td>≥ 40 mm</td></tr>
| |
| <tr><td>Asymptomatic with pulmonary hypertension</td><td colspan=2>LV EF > 60 percent and pulmonary artery systolic pressure >50-60 mmHg</td></tr>
| |
| <tr><td>Asymptomatic and chance for a repair without residual MR is >90%</td><td>> 60 percent</td><td>< 40 mm</td></tr>
| |
| </table>
| |
| | |
| ==Epidemiology==
| |
| It has a [[Prevalence (epidemiology)|prevalence]] of approximately 2% of the population, affecting males and females equally.<ref>[http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/mitral-valve-disease/ The Cleveland Clinic Center for Continuing Education > Mitral Valve Disease: Stenosis and Regurgitation] Authors: Ronan J. Curtin and Brian P. Griffin. Retrieved September 2010</ref> It is one of the two most common valvular heart disease in the elderly.<ref name=uptodate>[http://www.uptodate.com/patients/content/topic.do?topicKey=~PxxZxAzdJkaEgaZ Valvular heart disease in elderly adults] Authors: Dania Mohty, Maurice Enriquez-Sarano. Section Editors:Catherine M Otto, Kenneth E Schmader. Deputy Editor: Susan B Yeon. This topic last updated: April 20, 2007. Last literature review version 18.2: May 2010</ref>
| |
| | |
| ==References==
| |
| {{reflist|2}}
| |
| | |
| ==External links==
| |
| * [http://www.realites-cardiologiques.com/film-mitraclip MitraClip Film]
| |
| *[http://www.wikiecho.com/wiki/index.php?title=Mitral_regurgitation Echocardiographic features of mitral regurgitation at Wikiecho]
| |
| * [http://heartcenter.seattlechildrens.org/conditions_treated/mitral_valve_abnormalities.asp Mitral Regurgitation information] from Seattle Children's Hospital Heart Center
| |
| * [http://www.heart-valve-surgery.com/heart-surgery-blog/2014/01/08/mitral-regurgitation-infographic/ Educational Infographic about Mitral Regurgitation for patients, their families and friends]
| |
| | |
| {{Circulatory system pathology}}
| |
| {{Congenital malformations and deformations of circulatory system}}
| |
| | |
| {{DEFAULTSORT:Mitral Regurgitation}}
| |
| [[Category:Valvular heart disease]]
| |
| [[Category:Chronic rheumatic heart diseases]]
| |
| | |
| {{Link FA|de}}
| |