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Mitral Valve Regurgitation

Overview

Picture of 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. Many people with this problem may have a valve that is prone to wear and tear. As the person gets older, the valve gets weak and no longer closes tightly. Other causes include heart failure, rheumatic fever, congenital heart disease, a calcium buildup in the valve, and other heart problems.
  • 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?

If you have mild to moderate chronic mitral valve regurgitation, you may never have symptoms. If you have moderate to severe disease, you may not have symptoms for decades.

If your heart weakens because of your mitral valve, you may start to have symptoms of heart failure. Call your doctor if you have any of these symptoms:

  • 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 and to look for coronary artery disease.

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 regularly checking your heart to make sure it is working properly. You may take medicines to relieve symptoms or to prevent or treat complications. Medicines include:

You may need surgery to repair or replace your mitral valve if you get symptoms of heart failure, if the size of your left ventricle (your heart's main pumping chamber) increases, or if your heart weakens.

If you have chronic mitral valve regurgitation, your doctor may want you to make some lifestyle changes to ease the load on your heart.

  • You may need to be careful about physical activity. Talk to your doctor before starting an exercise program.
  • You may need to cut down on salt in your diet.

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

Chronic mitral valve regurgitation is caused by diseases or conditions that damage the mitral valve over time. The valve then allows blood to leak backward (regurgitate).

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).

Examples of diseases or conditions that can cause mitral valve regurgitation 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.

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.

Chronic mitral valve regurgitation

If you have mild-to-moderate chronic mitral valve regurgitation, you may never develop symptoms. If you have moderate-to-severe disease, you may not have symptoms for decades. Depending on the severity of your mitral valve regurgitation and condition of your heart, you may not develop symptoms of heart failure for many years.

Symptoms appear as the left ventricle expands to accommodate the larger amount of blood (volume overload) flowing into the chamber. The larger the left ventricle, the more advanced the MR. Symptoms 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.

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.

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.
  • Coronary artery disease (CAD). CAD may cause ischemia (reduced blood flow) or infarction (heart attack), which affects the valve's structure. This can lead to incomplete closure.
  • Less commonly, diabetes and Marfan's syndrome, because they may lead to hardening of the valve.

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.
  • Coughing up blood.
  • A decreased ability to exercise at your usual level.
  • Excessive fatigue (without other explanation).

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 every 6 to 12 months or 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.

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.

Chest X-ray

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.

Cardiac catheterization

Cardiac catheterization, a test that evaluates your heart and heart (coronary) arteries, may be done to:

  • Confirm the severity of mitral valve leakage seen on an echocardiogram.
  • Check for coronary artery disease before valve repair or replacement surgery. If severe blockage is seen in the coronary arteries, the blockage may be corrected during the same open-heart surgery to correct the damaged valve.

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.

Monitoring chronic mitral valve regurgitation

Severity of mitral regurgitation

Suggestions for monitoring and tracking

Mild
  • See a doctor annually for a checkup.
  • Let your doctor know if you have symptoms in between visits.
Moderate
  • See a doctor annually.
  • Let your doctor know if you have symptoms in between visits.
Severe
  • Have a physical exam and echocardiogram every 6–12 months.

Treatment Overview

Treatment for chronic mitral valve regurgitation (MR) includes monitoring your heart function and symptoms, as well as treating symptoms as they develop. If MR becomes severe, the mitral valve will 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 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.

The echocardiogram uses painless ultrasound waves to check how well your heart is pumping blood (ejection fraction) and to measure the size of your left ventricle. The smaller the ejection fraction, the harder your heart must work to pump a sufficient volume of blood.

Medicine. Your doctor may prescribe medicines to relieve symptoms or treat complications. For more information, see Medications.

Surgery. Valve repair or replacement surgery might be recommended if:1

  • You have symptoms.
  • Regurgitation is severe.
  • Your heart has pumping problems (low ejection fraction).
  • Your left ventricle is larger than normal.

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 is done immediately to replace or repair the valve.

Ongoing Concerns

Chronic 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:

Living With Mitral Valve Regurgitation

Watch for symptoms. After you are diagnosed with mitral valve regurgitation (MR), it is important to watch for symptoms of heart failure. These symptoms show that your heart is weakening and MR is getting worse. Symptoms of heart failure include shortness of breath, fatigue, and swelling in your feet and ankles. If new symptoms develop or if your symptoms become worse, call your doctor.

Be active. 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.

Limit sodium. Your doctor may advise you to limit sodium in your diet. If you consume too much salt, it will cause your body to retain excess fluid. Most of the sodium in our diets comes from processed foods, not the salt shaker. Foods to avoid include potato chips, pretzels, salted nuts, processed meats and cheeses, pizza, canned soups, canned vegetables, olives, fast foods, and frozen dinners (unless the label clearly states the product is low-sodium).

When you are grocery shopping, check labels carefully for sodium content. Your doctor may advise you to limit salt to less than 2,300 mg a day. Add more fresh fruit and vegetables to your diet to replace foods high in sodium. Read labels carefully to identify sources of hidden sodium in your diet.

Prevent endocarditis. Take good care of your teeth, and see your dentist regularly. 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.

Medications

Medicines do not prevent or correct the damage to the heart caused by mitral valve regurgitation (MR). In chronic regurgitation, they might be used in some people to reduce the severity of regurgitation. Or they might be used to treat complications of mitral regurgitation. In acute regurgitation, medicine is used as emergency treatment before surgery.

Chronic regurgitation

In chronic MR, you probably won't need medicines unless you have symptoms.

People with chronic and severe MR who also have an enlarged, abnormally functioning left ventricle may not benefit from mitral valve surgery and are often treated with medicines to try to relieve their symptoms. Depending on the severity of their MR, some older people may also be treated with medicines because they may not be good candidates for surgery. That's because they are at greater risk for developing complications during or following surgery.

Vasodilators. You might take these medicines if you have symptoms or high blood pressure or if your heart is not pumping blood as well as normal.

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.

Medicine after surgery. If you have surgery for mitral regurgitation, you will likely take a blood thinner. Blood thinners prevent blood clots. Blood thinners include antiplatelet medicine, such as aspirin, or anticoagulant medicine, such as warfarin. 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. Vasodilators such as nitroprusside help reduce the amount of blood flowing back into the left atrium. Diuretics help reduce workload on the heart.

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:

Surgery

If your chronicmitral valve regurgitation (MR) becomes severe or you have symptoms of heart failure, such as shortness of breath, swelling, and fatigue, surgery to repair or replace your mitral valve will be needed.

Surgery is usually delayed if no symptoms or signs of heart failure are present. Your doctor will check for symptoms and check your heart during your regular visits. If follow-up tests show enlargement or abnormal function of the left ventricle, then the doctor usually recommends surgery.

Some doctors believe it's best to repair or replace the valve before you develop severe symptoms, because it leads to better long-term health. On the other hand, surgery is a major procedure that has its own risks and complications. Even if you have no symptoms, talk to your doctor about the benefits of surgery and about your heart's condition, your age, and your overall health.

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.

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.

Repair

If mitral valve repair is done before the heart is severely damaged by the faulty valve, most people have excellent short- and long-term results.1

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?

Other Places To Get Help

Organizations

Society of Thoracic Surgeons
 
633 North Saint Claire Street
Floor 23
Chicago, IL 60611
Phone: (312) 202-5800
Fax: (312) 202-5801
Web Address: www.sts.org
 

The Society of Thoracic Surgeons provides patient information on surgeries of the chest and throat that are done by cardiothoracic surgeons. These surgeries include heart, lung, and throat surgery. The patient information section of the website describes diseases, surgeries, patient options, and what to expect after surgery. And using the website, you can search for surgeons in your area.


American Heart Association (AHA)
7272 Greenville Avenue
Dallas, TX  75231
Phone: 1-800-AHA-USA1 (1-800-242-8721)
Web Address: www.heart.org
 

Visit the American Heart Association (AHA) website for information on physical activity, diet, and various heart-related conditions. You can search for information on heart disease and stroke, share information with friends and family, and use tools to help you make heart-healthy goals and plans. Contact the AHA to find your nearest local or state AHA group. The AHA provides brochures and information about support groups and community programs, including Mended Hearts, a nationwide organization whose members visit people with heart problems and provide information and support.


National Heart, Lung, and Blood Institute (NHLBI)
P.O. Box 30105
Bethesda, MD  20824-0105
Phone: (301) 592-8573
Fax: (240) 629-3246
TDD: (240) 629-3255
Email: nhlbiinfo@nhlbi.nih.gov
Web Address: www.nhlbi.nih.gov
 

The U.S. National Heart, Lung, and Blood Institute (NHLBI) information center offers information and publications about preventing and treating:

  • Diseases affecting the heart and circulation, such as heart attacks, high cholesterol, high blood pressure, peripheral artery disease, and heart problems present at birth (congenital heart diseases).
  • Diseases that affect the lungs, such as asthma, chronic obstructive pulmonary disease (COPD), emphysema, sleep apnea, and pneumonia.
  • Diseases that affect the blood, such as anemia, hemochromatosis, hemophilia, thalassemia, and von Willebrand disease.

References

Citations

  1. Bonow RO, et al. (2008). 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). Circulation, 118(15):

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.
  • Bonow RO, et al. (2008). 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). Circulation, 118(15):
  • 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.

Credits

By Healthwise Staff
Primary Medical Reviewer Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology
Specialist Medical Reviewer John A. McPherson, MD, FACC, FSCAI - Cardiology
Last Revised November 29, 2011

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