Mitral Regurgitation

Q: What is mitral valve regurgitation?

A: Regurgitation is the backward flow of blood into your heart. This occurs when your heart's mitral valve doesn't close tightly. When the mitral valve doesn't work properly, blood can't move through your heart or to the rest of your body as efficiently as it should, making you feel tired or out of breath. Mitral valve regurgitation is also called mitral insufficiency or mitral incompetence.

Q: What causes mitral valve regurgitation?

A: Mitral valve regurgitation can be caused by many things, including mitral valve prolapse, damaged tissue cord, rheumatic fever, endocarditis, wear and tear on the valve, prior heart attack, untreated high blood pressure, and congenital heart defects. See below for more on each of the causes of mitral valve regurgitation.

Q: What is mitral valve prolapse?

A: 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.

Q: How is mitral regurgitation occurs with damaged tissue cords?

A: 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.

Q: How does rheumatic fever affect the mitral valve?

A: Rheumatic fever is a complication of untreated strep throat and was once a common childhood illness in the United States. 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.

Q: How does a prior heart attack affect the mitral valve?

A: 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.

Q: Can untreated high blood pressure lead to mitral valve regurgitation?

A: Yes, 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.

Q: Do symptoms change with the severity of mitral valve regurgitation?

A: Yes, signs and symptoms of mitral valve regurgitation depend on its severity and how quickly the condition develops.

Q: What are the symptoms of mitral valve regurgitation?

A: 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
  • Lightheadedness
  • Cough, especially at night or when lying down
  • Heart palpitations — sensations of a rapid, fluttering heartbeat
  • Swollen feet or ankles
  • Excessive urination

Q: Will I always have symptoms if I have mitral valve regurgitation?

A: 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.

Q: If I have mild mitral valve regurgitation, am I at risk for other complications?

A: No, mild mitral valve regurgitation is unlikely to cause other problems.

Q: What are the complications of severe mitral regurgitation?

A: Severe mitral regurgitation may lead to complications including heart failure, atrial fibrillation, endocarditis, and pulmonary hypertension.

Q: What are complications associated with arrhythmias in mitral valve regurgitation?

A: Arrhythmias in combination with mitral regurgitation are associated with clots to other areas of the body, endocarditis (infection of the heart valve), heart failure, pulmonary emboli (blood clots in the lungs), and stroke.

Q: How is mild mitral valve regurgitation treated?

A: Mild mitral regurgitation may be observed without treatment. However, even if you don't have signs and symptoms with mitral valve regurgitation, the condition may require regular monitoring by your doctor. You may need regular evaluations, with the frequency depending on the severity of regurgitation. Observation is not the same as ignoring the condition. Working with your doctor, you should keep a close eye on your symptoms in case you do come to need treatment.

Q: Can mitral valve regurgitation be treated with medications?

A: 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.

Q: What are my surgical options for mitral valve regurgitation?

A: Surgical options include valve repair surgery or valve replacement surgery.

Q: Will I need surgery right away, or can I wait for a while?

A: 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.

Q: What is mitral valve repair?

A: Mitral valve repair is 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.

Q: What are the advantages of mitral valve repair?

A: Advantages include better early and late survival, improved lifestyle, better preservation of heart function, lower risk of stroke and infection (endocarditis), and no need for blood thinners (anticoagulation).

Q: Does NewYork-Presbyterian/Columbia offer any other surgical options for mitral valve regurgitation?

A: Yes, our surgeons now treat mitral valve regurgitation with a minimal access approach known as the "Bow Tie" procedure, which is extremely effective in curing this disorder. In addition, through the EVEREST II clinical trial, our physician-scientists are investigating a non-invasive approach using the Evalve clip to treating mitral valve regurgitation.

Q: Is there a minimally invasive approach to mitral valve regurgitation at NewYork-Presbyterian/Columbia?

A: Yes, our surgeons routinely perform mitral valve repair and replacement minimally invasively. The NYP/Columbia approach utilizes a 2-inch minithoracotomy incision and central aortic cannulation, avoiding the risks of peripheral (femoral) arterial access. All types of complex mitral repairs are possible through this approach, as well as common adjunctive procedures, such as the modified MAZE procedure for atrial fibrillation, ASD or PFO repair, or tricuspid valve procedures.

Q: What is the likelihood that a leaking mitral valve can be successfully repaired?

A: It is nearly 100%. The most common cause of mitral regurgitation is a condition called degenerative mitral valve disease, which is also called mitral valve prolapse, myxomatous mitral valve disease, and a floppy mitral valve. Such valves can be repaired in more than 95% of patients.

Q: How often can a leaky mitral valve be repaired minimally invasively?

A: When a patient requires isolated mitral valve surgery for a degenerative valve, at NYP/Columbia we can usually perform the operation through a 2 to 4 inch skin incision. We offer several different minimally invasive approaches, including a small incision on the right chest, a small incision in the mid-line, and robotically assisted procedures. Expertise with several approaches enables us to determine the best procedure for each patient, optimizing results.

Q: What risks are associated with mitral valve surgery?

A:For asymptomatic patients having mitral valve repair, the operative risk is approximately 1 in 1000. Risk in symptomatic patients remains well under 1%. The presence of coronary artery disease or other conditions that require surgical treatment will affect your individual risk.

Q: How long will mitral valve repair last?

A: After mitral valve repair, 95% of patients are free of reoperation at 10 years, and this statistic is similar at 20 years. Thus, reoperation is rare after a successful mitral valve repair. An echocardiogram is suggested yearly to assess valve function.

Q: Is mitral valve replacement the primary treatment for mitral valve regurgitation?

A: No, valve replacement is done only when valve repair is not possible.

Q: What is mitral valve replacement surgery?

A: 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.

Q: How is mitral valve replacement surgery performed?

A: Mitral valve repair or replacement requires open-heart surgery under general anesthesia. With traditional open-heart surgery, an incision 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.

Q: Does surgery eliminate mitral valve regurgitation?

A: Mitral valve regurgitation can be eliminated with surgery, but some people may continue to have some leakage. How well you do depend 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.

Q: What risks are associated with mitral valve surgery?

A: The risks for isolated mitral valve repair or aortic valve surgery are minimal, and are similar to any surgery. They include the risk of bleeding, infection, pneumonia, organ failure, stroke, and even a small risk of death. In general, these complications are expected in less than 5% of patients. During pre-operative consultations with our surgeons, patients are told what their specific risks are.

Q: How long will it take to feel well after mitral valve surgery?

A: Most patients typically feel better as soon as their valve is repaired. It takes about two to three weeks for most patients to feel well, although some healing and recovery may still continue in the following weeks and months.