Download Mitral Valve Regurgitation The mitral valve is one of four valves that

Mitral Valve Regurgitation
The mitral valve is one of four valves that regulate blood flow through the heart. The
mitral valve is located between the left upper and left lower chamber of the heart (left
atrium and left ventricle, respectively).
Mitral valve regurgitation (or insufficiency, as it is sometimes called) may be the result of
a condition called mitral valve prolapse, in which the valve leaflets and the fibers, or
cords, that support them become floppy and elongated. Mitral valve prolapse does not
always lead to regurgitation. In fact, many people who have mitral valve prolapse never
develop severe leaking of the mitral valve.
Patients with mitral regurgitation rarely have symptoms until the valve is leaking
severely. These symptoms include difficulty breathing, trouble exercising and fatigue.
Physicians often recommend treatment for severe mitral regurgitation before symptoms
develop.
Severe mitral regurgitation over time can lead to an increase in the size of the heart (left
atrium and ventricle), a decrease in the amount of blood flow to the body and an
increase in the work of the heart. Failure of the left ventricle may result.
Treatments for Mitral Regurgitation
Depending on the severity of your heart valve disease, your cardiologist may
recommend the following:
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Medications and salt restricted diet
Surgical treatment
Non-surgical, less invasive treatment
Medications
No medications have been proven to help the flaps of the mitral valve close properly.
However, your doctor may recommend medications to help reduce the symptoms of
mitral regurgitation.
If you are diagnosed with mild (grade 1) or moderate (grade 2) mitral regurgitation, your
doctor may decide the best care approach is to monitor your condition and prescribe
drugs to help treat its symptoms. These medications may include the following:
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Diuretics: Drugs that help reduce fluid accumulation in your body by increasing
fluid loss through urination.
Medications to decrease high blood pressure, which can complicate mitral
regurgitation. Your doctor may recommend you take one or more of these
antihypertensive medications to help manage your blood pressure:
o Beta blockers, which act to reduce heart rate and the heart’s output of
blood
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o Vasodilators, which act to dilate (widen) blood vessels. Examples include
ACE inhibitors and calcium channel blockers.
Antibiotics: Drugs that kill bacteria may help prevent or treat endocarditis, an
infection of the heart valves. However, the American Heart Association no longer
recommends that people with narrowed heart valves take antibiotics prior to
routine dental cleaning..
Salt (Sodium) Restriction: Foods high in salt (sodium) can cause fluid retention
and worsen symptoms related to heart valve disease. A low salt diet of only 2-3
grams of sodium per day is recommended, which means that salt should not be
added to food, and high sodium foods such as deli meats, nuts, canned soup,
and fast food should be avoided.
Even if you are on medications, you may notice an increase in fatigue or shortness of
breath. If this occurs, you should let your doctor know immediately.
Surgical Treatments
If you are diagnosed with moderate to severe (grade 3) or severe (grade 4) mitral
regurgitation, your doctor may recommend a surgical treatment.
One measure used to determine whether a surgical approach should be taken is called
the “ejection fraction.” The ejection fraction measures the fraction of blood that your
heart’s left lower chamber is able to pump to the body during a heartbeat.
Surgery is recommended to treat the mitral valve if the ejection fraction drops below 55
percent, or if the left ventricle is enlarged (larger than 45 millimeters). Your doctor may
recommend surgical treatment of the valve if a chance in your left ventricle is detected
by ultrasound, even if you do not have symptoms.
Depending on your condition, your doctor may recommend either of these two surgical
approaches:
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Mitral valve repair or
Mitral valve replacement
Valve repair, when possible, is preferred over valve replacement. Heart function is
usually better if your valve can be repaired. And complications are typically fewer than
with valve replacement.
What to expect
Before surgery, you will receive a general anesthetic, which is a medicine that will put
you into a deep sleep during the procedure. During the surgery, your doctor will make
an incision (cut) along the length of your breastbone (the flat bone in the center of your
chest) to expose your heart.
You will be connected to a heart-lung bypass machine, which will take over your
breathing and blood circulation during the surgery. The surgeon will stop your heart,
make a cut in it to expose the valve, then repair or replace the valve.
Mitral valve repair
Various techniques may be used alone or in combination to repair the mitral valve:
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Leaflet resection, in which the surgeon “re-models” the leaflets by removing
some portion of the leaflet tissue and reconnecting the leaflets with sutures;
Annuloplasty, in which the surgeon implants a ring (a collar-like structure) around
the opening of the mitral valve to make it smaller.
Edge-to-Edge, a procedure in which the surgeon fastens portions of the valve
leaflets together.
Chordal transposition, in which the surgeon repositions and reattaches the fibers
(Chordae tendineae) that connect the muscles in the left ventricle to the mitral
valve leaflets.
Newer surgical techniques use endoscopy to perform these procedures. Endoscopy
requires smaller incisions and involves robotic surgical techniques.
Mitral valve replacement
If your valve cannot be repaired and it must be replaced, your surgeon will implant an
artificial, or prosthetic, valve. An artificial valve can be either mechanical (made of
metallic components) or tissue.
Mechanical valves
Mechanical valves are devices made of metallic materials, such as titanium. They offer
life-long durability and rarely need to be replaced. The main risk with mechanical valves
is blood clot formation (thromboembolism). In order to prevent blood clots after receiving
a mechanical valve, you will need to take blood thinners for the rest of your life.
A secondary risk is associated with taking the blood-thinning medications. Bloodthinning medications increase the risk of bleeding. If the blood-thinning drugs make the
blood too “thin,” you can experience excessive bleeding even with minor cuts. If the
blood is too “thick,” clots can form on the valve that can later break off and lodge in the
blood vessels to the heart or brain, increasing the risk of heart attack or stroke.
Careful monitoring to ensure the correct levels of anticoagulation medications is critical.
It may require a monthly visit to the doctor’s office. New home monitoring units may
make it possible to regulate your blood-thinning medications without going to the
doctor’s office.
Tissue valves
Tissue valves are made of valve tissue taken from a cow (bovine), pig (porcine) or
human cadaver (homograft). Because tissue valves do not encourage blood clot
formation, patients who receive them do not need to take blood-thinning medicines for
very long.
However, tissue valves have not historically been as long lasting as mechanical valves.
A tissue valve (also called a bioprosthetic) can wear out over a period of 10 to 15 or
more years. If it deteriorates significantly, the valve must be replaced. Replacement, of
course, requires repeat surgery. Because of durability concerns, tissue valves are
implanted primarily in older patients. However, they have improved steadily and are
being used more and more frequently.
Risks of heart valve surgery
 Death. The overall mortality risk (risk of death) for heart valve surgery is less than
5 percent (5 out of every 100 patients).
 Irregular heart beat or arrhythmia. Arrhythmias can make you tired or short of
breath and put you at risk of blood clots. You may need to take anticoagulant
(blood thinning) medications to lower the risk of blood clots, which may form in
the heart due to irregular heart beat.
 Infection. After valve surgery, you may be prone to endocarditis, an infection or
inflammation of the heart valves. It occurs when bacteria enter the bloodstream
and infect damaged valve leaflets. People who have abnormal or damaged heart
valves or who have received an artificial heart valve are more vulnerable to the
infection.
 Risks associated with being put to sleep with general anesthesia.
 Risks, such as bleeding, associated with surgery.
After valve surgery
Your recovery in the hospital may last from four to 10 days, depending on your
condition. You may spend the first days after surgery in an intensive care unit (ICU)
where your heart will be closely monitored.
While in the ICU, you may have a number of tubes in your body to help recovery,
including a tube to help you breathe, a tube to drain fluids from the stomach while you
are not eating, tubes to drain fluid from your chest, a small tube to empty your bladder
and a tube in your arm to measure blood pressure. These will be removed when you
are moved out of the ICU to another care unit.
You will receive therapy to prevent complications such as pneumonia, collapsed lung or
infection. A nurse or therapist may lead you in deep breathing exercises and coughing
and encourage you to move your legs to lower the chance of blood clot formation. Your
therapy may also include gentle patting on the back to loosen fluids in the lungs.
Physical therapy will also be part of the recovery process. In the hospital, you will be
encouraged to walk around and you will be shown how to move your arms without
hurting your breastbone. Pain medication will ease the discomfort of the surgical
insicion and you will also learn how to do daily activities in ways that will not interfere
with the healing process.
Non-Surgical, Less Invasive Treatments
New, experimental approaches that do not require open heart surgery are being
developed to repair the mitral valve and stop mitral regurgitation.
These approaches use a catheter, a small flexible tube threaded through the arteries
from the upper thigh to the heart. Several approaches are under development, but have
not been approved in the United States by the Food and Drug Administration.
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In one approach, a mechanical clip (not unlike a tiny clothespin), is guided to the
mitral valve through the catheter. The clip catches the edges of the valve’s
leaflets to pull them together and improve their ability to stop blood from leaking
back into the upper left chamber. Doctors have collected three years of results
with the clip in a non-random study. A study is underway to compare the clip’s
effectiveness with that of surgical repair.
In another approach, doctors are exploring ways to thread a spring-type device
through the arteries that can change the shape and size of the annulus, the ring
of tissue that encircles the opening of the mitral valve. A change in size and
shape of the annulus is intended to help the valve leaflets close properly.