Mitral regurgitation: medical treatment, valve intervention and investigations
THE CONTEXT
Management depends on severity, symptoms and ventricular function, with regular clinical and echocardiographic reassessment.
Medical treatment and follow-up
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Moderate mitral regurgitation can be treated medically with diuretics and vasodilators.
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If atrial fibrillation is present, digoxin and anticoagulation should be given, with anticoagulation depending on the CHA₂DS₂-VA score.
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Systemic hypertension should be treated with vasodilators such as ACE inhibitors or ARBs because high afterload may worsen regurgitation.
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All patients require regular clinical and echocardiographic review.
Indications and considerations for intervention
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Worsening symptoms, progressive cardiomegaly or echocardiographic evidence of deteriorating left ventricular function indicate mitral valve replacement or repair.
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Mitral valve repair is the treatment of choice for severe mitral regurgitation because early repair appears to prevent irreversible left ventricular damage.
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Mitral regurgitation often accompanies left ventricular failure associated with coronary artery disease. During coronary artery bypass graft surgery, the valve is commonly repaired with an annuloplasty ring to tighten the annulus and improve leaflet coaptation.
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When ventricular impairment, dilatation and mitral regurgitation coexist, identifying the predominant problem can be difficult. If ventricular dilatation causes the regurgitation, valve repair or replacement may worsen ventricular function.
Investigation findings
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The electrocardiogram may show P mitrale and atrial fibrillation.
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Chest radiography may show enlarged left atrial and left ventricular chambers, pulmonary venous congestion and, in acute regurgitation, pulmonary oedema.
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Echocardiography may show left atrial and left ventricular dilatation, a dynamic left ventricle unless myocardial dysfunction predominates, and structural mitral valve abnormalities.
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Doppler detects and quantifies regurgitation. Cardiac catheterisation may demonstrate chamber dilatation, mitral regurgitation, pulmonary hypertension and coexisting coronary artery disease.