Overview
Due to damage to the structure and function of the mitral valve, when the left ventricle contracts, the mitral valve is unable to close completely and blood regurgitation occurs.
Main manifestations include dyspnea, fatigue, panic, chest pain, etc.
Can be caused by rheumatic fever, degenerative changes, infective endocarditis, ischemic heart disease, dilated cardiomyopathy, etc.
Can be treated with general therapy, drug therapy, interventional therapy and surgery.
Definition
Mitral valve insufficiency is a condition in which blood flows back into the left atrium during contraction of the left ventricle due to abnormalities in the anatomy and/or function of the mitral valve.
The mitral valve is a “one-way valve” between the left atrium and the left ventricle that controls blood flow and ensures that blood flows from the left atrium into the left ventricle without backflow. If the mitral valve does not close properly when the left ventricle contracts, blood will flow backward, and this is called mitral insufficiency.
The structure of the mitral valve consists of four parts: the leaflets, the annulus, the tendon cords, and the papillary muscles, and lesions affecting any one or more of these structures can produce insufficient closure.
Staging
According to the rate of progression and duration of the disease, it can be categorized as acute or chronic.
Acute mitral valve insufficiency: rapid progression, severe disease, short course. It is often caused by rupture of the tendon cords, destruction or rupture of the valve, necrosis or rupture of the papillary muscles, and dehiscence after prosthetic valve replacement.
Chronic mitral valve insufficiency: slow progression and long course. It can be caused by rheumatic fever, coronary atherosclerotic heart disease (CHD), dilated cardiomyopathy, valvular degeneration, and connective tissue disease.
Morbidity
In our patients with mitral valve closure insufficiency, rheumatic lesions used to be the most common, accounting for about 1/3 of all patients with mitral valve closure insufficiency. it is now most common in ischemic cardiomyopathy and dilated cardiomyopathy, and is more common in men than in women.
Etiology
Causes
Chronic rheumatic fever
Chronic inflammation and fibrosis caused by repeated episodes of rheumatic fever can lead to shortening, sclerosis, deformation of the leaflets, and adhesion of the tendon cords.
Degenerative lesions
Mitral valve prolapse, due to mucinous degenerative lesions of the mitral valve leaflets, causing relaxation of the mitral valve leaflets or excessive length of the tendon cords, leading to mitral valve closure insufficiency.
Calcification of the mitral annulus may affect the normal activity of the leaflets in severe cases, preventing complete closure of the mitral valve during left ventricular systole.
Coronary atherosclerotic heart disease (CHD)
When myocardial ischemia is severe, insufficient blood supply causes papillary muscle insufficiency, which in turn weakens the pull of the papillary muscles on the tendon cords and valve leaflets, and can result in mitral valve closure insufficiency.
Infective endocarditis
Perforation or shortening of the mitral valve leaflets, rupture of the tendon cords or papillary muscles, and abscess of the mitral annulus can result in mitral valve closure insufficiency.
Left ventricular dilatation
For example, dilated cardiomyopathy can lead to enlargement of the mitral valve annulus while the mitral valve leaflets fail to grow accordingly, as a result, the two mitral valve leaflets fail to close completely when the mitral valve is closed, resulting in mitral valve closure insufficiency.
Congenital Defects
Marfontein syndrome is a connective tissue genetic defect disorder that often causes aortic coarctation. When the lesion affects the mitral valve, it can cause mitral valve prolapse.
Congenital structural anomalies, such as congenital dilated mitral annulus, congenital rupture of the tendon cords, and congenital cleft or perforation of the mitral leaflets, can cause mitral valve closure insufficiency.
Other
Connective tissue diseases, as seen in systemic lupus erythematosus and scleroderma. Fibrin-like degeneration can cause leaflet adhesions and contractures, leading to mitral valve closure insufficiency.
Severe trauma, severe crush injuries, or burst injuries can cause dislodgement or displacement of the mitral annulus, or tearing of the mitral leaflets, or rupture of the tendon cords, all of which can lead to mitral valve closure insufficiency.
Periprosthetic heart valve leakage, with poor surgical suturing, resulting in cracks where the prosthetic valve attaches to the left atrioventricular groove.
Risk Factors
History of mitral valve prolapse or mitral stenosis: A family history of valve disease may increase the risk of developing the condition.
Infections: such as frequent periodontitis, upper respiratory or gastrointestinal infections.
Use of certain medications: People who take medications containing ergotamine or who take carbamazepine have an increased risk of mitral regurgitation.
Age: Older people have mitral valve closure insufficiency due to the natural degeneration of the valve.
Unhealthy lifestyle habits: chronic smoking, alcohol consumption, and lack of exercise.
Other diseases: such as high blood pressure, diabetes, obesity, etc.
Symptoms
Main Symptoms
Acute mitral valve insufficiency
In milder cases, there may be only mild dyspnea that occurs only after activity.
If the condition is more severe, symptoms such as severe dyspnea, sedentary breathing (only being able to relieve the dyspnea by sitting or half lying down), and even coughing up pink foamy sputum, as well as pale face, cold limbs, blurred consciousness, and unconsciousness, may suddenly appear.
Chronic mitral valve insufficiency
Mild patients may have no obvious symptoms for a long time.
Severe patients may have fatigue, palpitations, dyspnea after activity, and in the advanced stage, sedentary respiration, nocturnal paroxysmal dyspnea, and with the progress of the disease, abdominal distension, loss of appetite, lower limb or even generalized edema and oliguria (symptoms of cardiogenic edema), and so on.
Complications
Heart failure
Symptoms of left heart failure are mostly chest tightness or dyspnea; right heart failure is mainly characterized by fluid retention and edema.
Atrial Fibrillation
Manifestations include panic, chest tightness, and sweating. Atrial fibrillation is seen in 3/4 of people with chronic severe mitral valve closure insufficiency.
Consultation
Department of Medicine
Cardiovascular Medicine
Physical examination reveals the presence of mitral regurgitation, or symptoms such as dyspnea, fatigue, panic, chest pain, etc. Prompt medical attention is recommended.
Emergency Medicine
Sudden severe chest pain, dyspnea, etc., it is recommended to go to the Emergency Department immediately.
In case of loss of consciousness, respiratory and cardiac arrest, immediately call 120 emergency and perform CPR on the patient at the same time.
Preparation
Preparing for your visit: registration, information preparation, common problems
Tips for seeking medical treatment
Some patients with heart valve disease do not have obvious clinical symptoms, which are often detected during physical examination, and they need to consult a doctor in time to avoid the development of the disease.
Do not abuse drugs without doctor’s permission, so as to prevent drugs from affecting the relevant examinations and interfering with the diagnosis and treatment of the disease.
Preparation List
Symptom list
Especially need to pay attention to the time of occurrence of symptoms, special performance, etc.
What are the main symptoms?
Are palpitations, fatigue and shortness of breath after exertion present?
What are the triggers and relievers of the symptoms?
How many times a day do these symptoms occur? How long do they last?
Medical History Checklist
Is there a family history of related medical conditions?
Are there any drug or food allergies?
Any other medical conditions?
Checklist
Test results for the last 6 months, which can be brought to the doctor’s office
Blood tests
Blood biochemistry
Specialized tests
Echocardiogram
Chest X-ray
Ambulatory Blood Pressure Monitoring
Electrocardiogram and 24-hour ECG
Medication List
Medication used in the last 3 months, if available in a box or package, bring with you to the doctor’s office
Drugs to lower pulmonary venous pressure/Nitroprusside, Nitroglycerin
Beta blockers: propranolol, nadolol
Angiotensin-converting enzyme inhibitors: captopril, enalapril, benazepril
Calcium channel blockers: verapamil, diltiazem
Vasodilators: nitrates
Diuretics: furosemide, hydrochlorothiazide
Diagnosis
Diagnosis is based on
medical history
Family history of heart disease.
History of rheumatic fever, infective endocarditis.
History of hypertension, coronary heart disease, cardiomyopathy, etc.
Clinical manifestations
Symptoms
If the lesion is light and the cardiac function is well compensated, there may be no obvious symptoms; if the lesion is heavy or the duration of the disease is long, there may be symptoms such as palpitation, fatigue and shortness of breath after exertion.
Physical signs
The apical impulse is enhanced and shifted downward to the left.
On auscultation, a holosystolic murmur can be heard in the apical region, which is transmitted to the axilla, the first heart sound is weakened or disappeared, and the second heart sound in the pulmonary valve area is hyperactive.
Signs of right heart failure, such as jugular vein distension, hepatomegaly, and lower extremity edema, are seen in advanced stages.
Laboratory tests
Routine blood tests, C-reactive protein, cardiac enzymes, blood gas analysis, electrolytes, liver function, kidney function, etc. are often performed.
They can assess the physical condition, understand the function of important organs such as liver and kidney, and detect the cause of the disease as well as differentiate other diseases.
Imaging
X-ray
To understand the size of the heart shadow.
Chest X-ray heart shadow is enlarged, left atrium and left ventricle are mainly enlarged, esophagus barium meal X-ray can see the esophagus shifted backward by compression.
Avoid wearing metal jewelry or clothing with metal fittings during the examination.
Echocardiography
To understand the degree of ventricular wall thickness and mitral valve lesions.
The M-mode examination shows a bimodal or unimodal mitral valve curve with an increased rate of rise and fall. The anterior and posterior diameters of the left ventricle and left atrium are markedly enlarged. The posterior wall of the left atrium shows a pronounced wave of depression. In cases of combined stenosis, a rampart-like rectangular wave may still be seen.
Two-dimensional or cross-sectional echocardiography directly demonstrates the failure of the mitral valve orifice to close completely during cardiac contraction. Echocardiographic Doppler testing demonstrates diastolic blood turbulence, which can be used to estimate the severity of the closure insufficiency.
No special preparation is required before transthoracic echocardiography in adults, and normal meals can be taken.
Electrocardiogram
may be normal in mild cases and show leftward deviation of the electrical axis, mitral-type P waves, left ventricular hypertrophy and strain in more severe cases.
Avoid strenuous exercise and remain calm before the examination.
Cardiac catheterization
Ventriculography can be performed to understand mitral regurgitation and the degree of regurgitation, and to exclude other valvular diseases and coronary atherosclerotic heart disease, as well as to assess cardiac function.
Differential Diagnosis
Tricuspid valve insufficiency
Tricuspid valve insufficiency is asymptomatic in mild cases, but in severe cases, weakness, chest tightness, and dyspnea may occur. Echocardiography can be used for differential diagnosis.
Ventricular septal defect
Ventricular septal defects are usually asymptomatic in mild cases, but in severe cases, symptoms such as dyspnea, developmental delay, and dyspnea after activity may occur. Echocardiography can be used for differential diagnosis.
Aortic stenosis
Aortic stenosis may present with symptoms such as dyspnea, angina, and syncope. Echocardiography can be used for differential diagnosis.
Obstructive Hypertrophic Cardiomyopathy
Obstructive hypertrophic cardiomyopathy is characterized by palpitations, shortness of breath, headache, dizziness, etc. A small number of patients may suffer from syncope or even sudden death. Echocardiography can be used for differential diagnosis.
Pulmonary stenosis
People with pulmonary stenosis may experience dyspnea and fatigue during activities, and severe stenosis may lead to fainting or even sudden death due to strenuous activities. Differential diagnosis can be made by echocardiography.
Treatment
General treatment
For long time asymptomatic people, no special treatment is needed, mainly to prevent the occurrence of rheumatic fever and infective endocarditis, patients with coronary artery disease should improve myocardial ischemia, and need to be rechecked regularly.
Asymptomatic moderate mitral valve closure insufficiency with normal cardiac function can be reviewed once a year and echocardiography every 2 years; asymptomatic severe mitral valve closure insufficiency with normal cardiac function should be reviewed once every 6 months and echocardiography every year.
Strenuous exercise should be avoided.
Medication
Drugs cannot treat mitral valve insufficiency and are mainly used to improve cardiac function and systemic conditions.
Acute mitral valve insufficiency drug therapy is aimed at reducing pulmonary venous pressure (e.g., sodium nitroprusside, nitroglycerin, etc.) and increasing cardiac output (e.g., vasodilators, angiotensin-converting enzyme inhibitors, etc.), and it is generally a preoperative transitional measure.
Chronic mitral valve closure insufficiency with heart failure should limit sodium intake, and angiotensin-converting enzyme inhibitors, beta-blockers, diuretics and digitalis can be used.
Chronic mitral valve closure insufficiency with chronic atrial fibrillation, a history of embolism in the physical circulation, and thrombus in the left atrium should be treated with long-term anticoagulation.
Diuretics: such as furosemide, hydrochlorothiazide, etc., which can induce the excess salt and water within the body’s blood to be discharged from the body.
Vasodilators: relieve the symptoms of angina or dyspnea, improve hemodynamics and increase cardiac output, such as nitrates.
Angiotensin-converting enzyme inhibitors: can make both cardiac preload and afterload can be reduced, reduce counterflow. Such as captopril, perindopril, benazepril, etc.
Surgery
Indications
Symptomatic acute severe mitral valve closure insufficiency.
Chronic severe mitral valve closure insufficiency in cardiac function classes II, III, and IV, but left ventricular function is not yet severely impaired (severely impaired means left ventricular ejection fraction <0.30 and left ventricular end-systolic internal diameter ≥55 mm).
Chronic severe mitral valve closure insufficiency with mild to moderate impairment of left ventricular function (left ventricular ejection fraction 0.30 to 0.60, left ventricular end-systolic internal diameter ≥40 mm).
Asymptomatic but newly developed atrial fibrillation in patients with severe mitral valve closure insufficiency with good left ventricular function.
Asymptomatic but comorbid pulmonary hypertension (resting pulmonary artery systolic pressure ≥50 mmHg, post-exercise ≥60 mmHg) in patients with severe mitral insufficiency with good left ventricular function.
Chronic severe mitral valve closure insufficiency due to subvalvular structural dysfunction, cardiac function class III-IV, and severely impaired left ventricular function.
Patients with severe mitral valve closure insufficiency due to left ventricular enlargement of left heart insufficiency, cardiac function class III to IV, and unsuccessful treatment with anti-heart failure therapy including biventricular synchronous pacing.
Surgery is also recommended in patients with severe mitral valve insufficiency who are asymptomatic and have a 95% probability of viable repair as assessed preoperatively.
Surgical Procedures
Mitral valve repair: For patients with mild valve disease and good mobility. The mitral valve is repaired using the patient’s own tissue and some prostheses to restore valve integrity.
Mitral Valve Replacement: For those with severe mitral valve damage who are not suitable for repair and plasty.
Postoperative care
Monitor such as blood pressure, central venous pressure, etc. to judge the supplementation of blood volume; the speed of rehydration should not be too fast, so as not to aggravate the burden on the heart; observe the urine volume, record the hourly urine volume and 24-hour water intake and output; observe the changes of heart rate and heart rhythm, and be vigilant for the emergence of cardiac arrhythmia; observe the body temperature, skin temperature and color, and learn the peripheral vascular filling situation.
After surgery, bed rest is required for a period of time. During the period of bed rest, patients can turn over slowly with the help of others; after that, they can gradually start to get out of bed and move around, they can walk around the bedside first, gradually extend the activity time and expand the range of activities, and they can take a walk in the corridor under the condition of being accompanied by someone, and so on.
Do not remove the gauze, if the wound oozes blood, pain, or the gauze falls off, please ask the doctor to deal with it in time.
After waking up, if there is no nausea and vomiting, you can eat fluids such as water and rice soup first, and gradually transition to semi-liquid and normal diet.
Transcatheter Intervention
Transcatheter mitral valve leaflet edge-to-edge plasty (MitraClip system) is the most widely used technique in the field of transcatheter mitral valve intervention. The use of this device in China is still in the exploratory phase.
Function: The device uses edge-to-edge percutaneous repair to reduce mitral regurgitation, improve left ventricular function, and reverse left ventricular remodeling.
Indications: In the latest European and American guidelines, high-risk surgery, contraindication to surgery, and symptomatic severe primary mitral regurgitation are all indications for MitraClip.
Prognosis
Cure
Patients with acute mitral valve insufficiency who develop severe regurgitation with hemodynamic instability have an extremely high mortality rate without prompt surgical intervention.
Patients with chronic mitral insufficiency may remain asymptomatic for a significant period of time; however, once symptoms develop, the prognosis is poor. After diagnosis of chronic severe mitral valve insufficiency, the 5-year survival rate with medical therapy is 80% and the 10-year survival rate is 60%.
Most patients with simple mitral valve prolapse without significant regurgitation and systolic murmur have a good prognosis; those aged >50 years with significant systolic murmur and mitral regurgitation, leaflet redundancy and thickening, and enlarged left atrium and left ventricle have a poorer prognosis. Symptoms and quality of life improve in most patients after surgery, and survival is significantly better than with medical therapy.
Hazards
Symptoms such as dyspnea, fatigue and weakness, panic and chest pain may occur, affecting the normal life of patients.
Some patients will develop heart failure, which appears early in acute cases and later in chronic cases; atrial fibrillation is seen in 3/4 of chronic severe mitral valve closure insufficiency.
Mitral valve closure insufficiency, part of the left ventricle during cardiac systole blood reflux to the left atrium, so that the left atrium blood volume increases, pressure rises, left atrial compensatory dilatation hypertrophy. Further left atrial and left ventricular volumetric load increase occurs, so that the left ventricle compensatory hypertrophic dilatation, left heart failure.
Gradually after the left heart loss of compensation, pulmonary stasis, pulmonary hypertension, compensatory hypertrophy of the right ventricle, right heart failure and corporal circulation stasis appear.
Daily
Daily management
Dietary management
Food does not directly affect mitral valve insufficiency. But a healthy diet can help prevent other heart muscle diseases.
A balanced diet high in protein, rich in fiber and low in fat, with plenty of vegetables and fruits, whole grains, lean meats, fish and nuts should be consumed daily.
Smaller meals are recommended.
Life management
Stop smoking and drinking. Drinking large amounts of alcohol can cause arrhythmia and worsen symptoms. Excessive alcohol consumption can also cause cardiomyopathy.
Regular physical exercise. Choose the appropriate intensity of exercise and do not engage in strenuous exercise. Consultation with your doctor is recommended.
Maintain a healthy weight. Keep your weight within the range recommended by your doctor.
Control blood pressure, which should be monitored regularly.
Avoid emotional stress and excessive fatigue and tension.
Prevent infective endocarditis. Treat skin infections, periodontitis, colds, pneumonia and gastrointestinal infections as they occur.
Tips on medication
Take cardiotonic, diuretic, potassium supplement and anticoagulant drugs as prescribed by the doctor. Do not add, reduce or change medication in the middle of the day.
Follow-up and review
Patients with mild disease should be reviewed every 3 to 5 years; patients with moderate disease should be reviewed every 1 to 2 years; patients with severe disease should be reviewed every 6 to 12 months.
If palpitations, chest tightness, dyspnea, subcutaneous bleeding and other discomforts occur, consult the doctor promptly.
Prevention
Etiologic prevention
Mitral valve insufficiency is mainly prevented by preventing and treating the primary cause.
Mitral valve closure insufficiency usually has a primary disease, so it is necessary to prevent and treat primary diseases such as rheumatic fever, coronary artery disease and hypertension.
Control blood lipids, blood pressure, blood sugar, and maintain a healthy weight.
Female patients in their childbearing years should use contraception so as not to aggravate the burden on the heart by pregnancy. If the desire to have children is strong, the physician should be consulted in detail to obtain appropriate guidance.
Living Habits
Pay attention to the indoor environment, open windows more often to keep indoor air circulation, which can reduce the chance of exposure to germs and viruses.
Do more outdoor activities, breathe fresh air, jogging, jumping rope, dancing, swimming and other sports, which can enhance their own immunity to resist the attack of foreign pathogens.
Pay attention to weather changes, appropriate increase or decrease in clothing, some abnormal symptoms should be timely medical treatment, so as to avoid aggravation of the condition, bringing more serious consequences.
Daily attention should be paid to nutrition, light diet, regular work and rest, quit smoking and drinking.