Mitral Regurgitation: Diagnosis and Timing of Intervention

  • Marta Chiarandà
  • Sarah Mangiafico
  • Salvatore Scandura
Chapter

Abstract

The clinical manifestations of mitral regurgitation (MR) are conditioned by the magnitude and rapidity of onset and the ability of the chambers of the heart to adapt from a hemodynamic and neuroendocrine perspective. Patients with MR are often asymptomatic despite a severe degree of valve regurgitation. The major symptom is dyspnea, at first on exertion and then at rest, accompanied by peripheral edemas, marked asthenia, and palpitations. The most serious clinical manifestation is acute pulmonary edema [1].

References

  1. 1.
    Woolley K, Stark P. Pulmonary parenchymal manifestations of mitral valve disease. Radiographics. 1999;19(4):965–72.Google Scholar
  2. 2.
    Rahimtoola SH, Dell’Italia LJ. Mitral valve disease. In: Fuster V, Alexander RW, O’Rourke RA, et al., editors. Hurst’s the heart. 11th ed. New York: McGraw-Hill; 2004. p. 1669–95.Google Scholar
  3. 3.
    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), Society of Cardiovascular Anesthesiologists, Bonow RO, Carabello BA, Chatterjee K, et al. 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) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol. 2006;48:1–148.CrossRefGoogle Scholar
  4. 4.
    Vahanian A, Baumgartner H, Bax J, et al. Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology ESC Committee for Practice Guidelines. Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007;28:230–68.PubMedGoogle Scholar
  5. 5.
    Bonow RO, Carabello BA, Chatterjee K, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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. Circulation. 2008;118:523–661.CrossRefGoogle Scholar
  6. 6.
    Zoghbi WA, Eriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography. J Am Soc Echocardiogr. 2003;16:777–802.CrossRefPubMedGoogle Scholar
  7. 7.
    Bargiggia GS, Tronconi L, Sahn DJ, et al. A new method for quantitation of mitral regurgitation based on color flow Doppler imaging of flow convergence proximal to regurgitant orifice. Circulation. 1991;84:1481–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Simpson IA, Shiota T, Gharib M, et al. Current status of flow convergence for clinical applications: is it a leaning tower of “PISA”? J Am Coll Cardiol. 1996;27:504–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Baumgartner H, Schima H, Kuhn P. Value and limitations of proximal jet dimensions for the quantitation of valvular regurgitation: an in vitro study using Doppler flow imaging. J Am Soc Echocardiogr. 1991;4:57–66.CrossRefPubMedGoogle Scholar
  10. 10.
    Sahn DJ. Instrumentation and physical factors related to visualization of stenotic and regurgitant jets by Doppler color flow mapping. J Am Coll Cardiol. 1988;12:1354–65.CrossRefPubMedGoogle Scholar
  11. 11.
    Pu M, Griffin BP, Vandervoort PM, et al. The value of assessing pulmonary venous flow velocity for predicting severity of mitral regurgitation: a quantitative assessment integrating left ventricular function. J Am Soc Echocardiogr. 1999;12:736–43.CrossRefPubMedGoogle Scholar
  12. 12.
    Thomas L, Foster E, Schiller NB. Peak mitral in flow velocity predicts mitral regurgi tation severity. J Am Coll Cardiol. 1998;31:174–9.CrossRefPubMedGoogle Scholar
  13. 13.
    Lancellotti P, Moura L, Pierard LA, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr. 2010;11:307–32.CrossRefPubMedGoogle Scholar
  14. 14.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW, American College of Cardiology, American College of Cardiology/American Heart Association, American Heart Association. 2014 AHA/ACC guideline 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. J Thorac Cardiovasc Surg. 2014;148(1):e1–32. doi: 10.1016/j.jtcvs.2014.05.014. Epub 9 May 2014.CrossRefPubMedGoogle Scholar
  15. 15.
    Lancellotti P, Gérard P, Piérard LA. Long term outcome of patients with heart failure and dynamic functional mitral regurgitation. Eur Heart J. 2005;26:1528–32.CrossRefPubMedGoogle Scholar
  16. 16.
    Enriquez-Sarano M, Basmadjian AJ, Rossi A, et al. Progression of mitral regurgitation: a prospective Doppler echocardiographic study. J Am Coll Cardiol. 1999;34:1137–44.CrossRefPubMedGoogle Scholar
  17. 17.
    Lancellotti P, Lebrun F, Piérard LA. Determinants of exercise-induced changes in mitral regurgitation in patients with coronary artery disease and left ventricular dysfunction. J Am Coll Cardiol. 2003;42:1921–8.CrossRefPubMedGoogle Scholar
  18. 18.
    Shiota T. Role of modern 3D echocardiography in valvular heart disease. Korean J Intern Med. 2014;29(6):685–702. doi: 10.3904/kjim.2014.29.6.685. Epub 31 Oct 2014. Review.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Sugeng L, Shernan SK, Salgo IS, et al. Live 3-dimensional transesophageal echocardiography initial experience using the fully-sampled matrix array probe. J Am Coll Cardiol. 2008;52:446–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Biaggi P, Gruner C, Jedrzkiewicz S, et al. Assessment of mitral valve prolapse by 3D TEE. J Am Coll Cardiol Img. 2011;4:94–7.CrossRefGoogle Scholar
  21. 21.
    Quader N, Rigolin VH. Two and three dimensional echocardiography for pre-operative assessment of mitral valve regurgitation. Cardiovasc Ultrasound. 2014;12:42. doi: 10.1186/1476-7120-12-42.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Altiok E, Hamada S, van Hall S, et al. Comparison of direct planimetry of mitral valve regurgitation orifice area by three-dimensional transesophageal echocardiography to effective regurgitant orifice area obtained by proximal flow convergence method and vena contracta area determined by color Doppler echocardiography. Am J Cardiol. 2011;107:452–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Yosefy C, Levine RA, Solis J, Vaturi M, Handschumacher MD, Hung J. Proximal flow convergence region as assessed by real-time 3-dimensional echocardiography: challenging the hemispheric assumption. J Am Soc Echocardiogr. 2007;20:389–96.CrossRefPubMedGoogle Scholar
  24. 24.
    Matsumura Y, Saracino G, Sugioka K, et al. Determination of regurgitant orifice area with the use of a new three-dimensional flow convergence geometric assumption in functional mitral regurgitation. J Am Soc Echocardiogr. 2008;21:1251–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Hopmeyer J, He S, Thorvig KM, et al. Estimation of mitral regurgitation with a hemielliptic curve-fitting algorithm: in vitro experiments with native mitral valves. J Am Soc Echocardiogr. 1998;11:322–31.CrossRefPubMedGoogle Scholar
  26. 26.
    Morris M, Araoz P. Advanced imaging of mitral valve disease. US Cardiol. 2011;8:24–9.Google Scholar
  27. 27.
    Zeng X, Levine RA, Hua L, Morris EL, Kang Y, Flaherty M, Morgan NV, Hung J. Diagnostic value of vena contracta area in the quantification of mitral regurgitation severity by color Doppler 3D echocardiography. Circ Cardiovasc Imaging. 2011;4(5):506–13. doi: 10.1161/CIRCIMAGING.110.961649. Epub 5 Jul 2011.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Glockner JF, Johnston DL, McGee KP. Evaluation of cardiac valvular disease with MR imaging: qualitative and quantitative techniques. Radiographics. 2003;23:9.CrossRefGoogle Scholar
  29. 29.
    Schnyder PA, Sarraj AM, Duvoisin BE, et al. Pulmonary edema associated with mitral regurgitation: prevalence of predominant involvement of the right upper lobe. AJR Am J Roentgenol. 1993;161:33–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Hayek E, Gring CN, Griffin BP. Mitral valve prolapse. Lancet. 2005;365:507–18.CrossRefPubMedGoogle Scholar
  31. 31.
    D’Ancona G, Mamone G, Marrone G, et al. Ischemic mitral valve regurgitation: the new challenge for magnetic resonance imaging. Eur J Cardiothorac Surg. 2007;32:475–80.CrossRefPubMedGoogle Scholar
  32. 32.
    Rubinshtein R, Glockner JF, Ommen SR, et al. Characteristics and clinical significance of late gadolinium enhancement by contrast-enhanced magnetic resonance imaging in patients with hypertrophic cardiomyopathy. Circ Heart Fail. 2010;3:51–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Guo YK, Yang ZG, Ning G, et al. Isolated mitral regurgitation: quantitative assessment with 64-section multidetector CT—comparison with MR imaging and echocardiography. Radiology. 2009;252:369–76.CrossRefPubMedGoogle Scholar
  34. 34.
    Gelfand EV, Hughes S, Hauser TH, et al. Severity of mitral and aortic regurgitation as assessed by cardiovascular magnetic resonance: optimizing correlation with Doppler echocardiography. J Cardiovasc Magn Reson. 2006;8:503–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Grossman W, Baim DS. Grossman’s cardiac catheterization, angiography and intervention. 7th ed. Baltimore: Lippincott Williams and Wilkins; 2006.Google Scholar
  36. 36.
    Braunwald E, Awe W. The syndrome of severe mitral regurgitation with normal left atrial pressure. Circulation. 1963;27:29–35.CrossRefPubMedGoogle Scholar
  37. 37.
    Chikwe J, Adams DH. State of the art: degenerative mitral valve disease. Heart Lung Circ. 2009;18:319–29.CrossRefPubMedGoogle Scholar
  38. 38.
    Delahaye JP, Gare JP, Viguier E, et al. Natural history of severe mitral regurgitation. Eur Heart J. 1991;12:5–9.CrossRefPubMedGoogle Scholar
  39. 39.
    Enriquez-Sarano M, Freeman WK, Tribouilloy CM, et al. Functional anatomy of mitral regurgitation: accuracy and outcome implications of TEE. J Am Coll Cardiol. 1999;34:1129–36.CrossRefPubMedGoogle Scholar
  40. 40.
    Thamilarasan M, Griffin B. Choosing the most appropriate valve operation and prosthesis. Cleve Clin J Med. 2002;69:668–703.CrossRefGoogle Scholar
  41. 41.
    Lee EM, Shapiro LM, Wells FC. Superiority of mitral valve repair in surgery for degenerative mitral regurgitation. Eur Heart J. 1997;18:655–63.CrossRefPubMedGoogle Scholar
  42. 42.
    Enriquez-Sarano M, Schaff HV, Orszulak TA, et al. Valve repair improves the outcome of surgery for mitral regurgitation. A multivariate analysis. Circulation. 1995;91:1022–228.CrossRefPubMedGoogle Scholar
  43. 43.
    Trichon BH, Felker GM, Shaw LK, et al. Relation of frequency and severity of mitral regurgitation to survival among patients with left ventricular systolic dysfunction and heart failure. Am J Cardiol. 2003;91:538–43.CrossRefPubMedGoogle Scholar
  44. 44.
    Ling LH, Enriquez-Sarano M, Seward JB, et al. Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med. 1996;335:1417–23.CrossRefPubMedGoogle Scholar
  45. 45.
    Tribouilloy CM, Enriquez-Sarano M, Schaff HV, et al. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical implications. Circulation. 1999;99:400–5.CrossRefPubMedGoogle Scholar
  46. 46.
    Crawford MH, Souchek J, Oprian CA, et al. Determinants of survival and left ventricular performance after mitral valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease. Circulation. 1990;81:1173–81.CrossRefPubMedGoogle Scholar
  47. 47.
    Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol. 1994;24:1536–43.CrossRefPubMedGoogle Scholar
  48. 48.
    Sherrid MV, Clark RD, Cohn K. Echocardiographic analysis of left atrial size before and after operation in mitral valve disease. Am J Cardiol. 1979;43:171–8.CrossRefPubMedGoogle Scholar
  49. 49.
    Nashef SA, Roques F, Michel P, et al. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg. 1999;16:9–13.CrossRefPubMedGoogle Scholar
  50. 50.
    Enriquez-Sarano M, Rossi A, Seward JB, et al. Determinants of pulmonary hypertension in left ventricular dysfunction. J Am Coll Cardiol. 1997;29:153–9.CrossRefPubMedGoogle Scholar
  51. 51.
    Carabello BA. The current therapy for mitral regurgitation. J Am Coll Cardiol. 2008;52:319–26.CrossRefPubMedGoogle Scholar
  52. 52.
    DiSalvo T, Acker MA, Dec GW, et al. Mitral valve surgery in advanced heart failure. J Am Coll Cardiol. 2010;55:271–82.CrossRefGoogle Scholar
  53. 53.
    Bishay ES, McCarthy PM, Cosgrove DM, et al. Mitral valve surgery in patients with severe left ventricular dysfunction. Eur J Cardiothorac Surg. 2000;17:213–21.CrossRefPubMedGoogle Scholar
  54. 54.
    Wu AH, Aaronson KD, Bolling SF, et al. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J Am Coll Cardiol. 2005;45:381–7.CrossRefPubMedGoogle Scholar
  55. 55.
    Gaasch WH, Meyer TE. Left ventricular response to mitral regurgitation: implications for management. Circulation. 2008;118:2298–303.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Marta Chiarandà
    • 1
  • Sarah Mangiafico
    • 1
  • Salvatore Scandura
    • 1
  1. 1.Division of CardiologyFerrarotto Hospital, University of CataniaCataniaItaly

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