Mitral valve regurgitation — also called mitral regurgitation, mitral insufficiency or mitral incompetence — is a condition in which your heart's mitral valve doesn't close tightly, allowing blood to flow backward in your heart. As a result, blood can't move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath.
Treatment of mitral valve regurgitation depends on how severe your condition is, whether it's getting worse and whether you have symptoms. For mild leakage, treatment may not be necessary.
You may need heart surgery to repair or replace the valve for severe leakage or regurgitation. Left untreated, severe mitral valve regurgitation can cause heart failure or heart rhythm problems (arrhythmias). Even people without symptoms should be seen and evaluated by a cardiologist and surgeon specializing in mitral valve disease to determine whether early intervention may be beneficial.
Many people with severe mitral valve regurgitation may not have symptoms, yet may still benefit from early mitral valve repair. Signs and symptoms of mitral valve regurgitation, which depend on its severity and how quickly the condition develops, can include:
- Blood flowing turbulently through your heart (heart murmur)
- Shortness of breath (dyspnea), especially with exertion or when you lie down
- Fatigue, especially during times of increased activity
- Heart palpitations — sensations of a rapid, fluttering heartbeat
- Swollen feet or ankles
Mitral valve regurgitation is often mild and progresses slowly. You may have no symptoms for decades and be unaware that you have this condition, and it might not progress.
Your doctor might first suspect you have mitral valve regurgitation upon detecting a heart murmur. Sometimes, however, the problem develops quickly, and you may experience a sudden onset of severe signs and symptoms.
When to see a doctor
If you have a murmur, you should see your doctor, who may recommend that you visit a cardiologist and get an echocardiogram. If you develop symptoms that suggest mitral valve regurgitation or another problem with your heart, see your doctor right away. Sometimes the first indications are actually those of mitral valve regurgitation's complications, including heart failure, a condition in which your heart can't pump enough blood to meet your body's needs.
How the heart works
The heart, the center of your circulatory system, consists of four chambers. The two upper chambers (atria) receive blood. The two lower chambers (ventricles) pump blood.
Four heart valves open and close to let blood flow in only one direction through your heart. The mitral valve — which lies between the two chambers on the left side of your heart — is comprised of two flaps of tissue called leaflets.
The mitral valve opens when blood flows from the left atrium to the left ventricle. Then the flaps close to prevent the blood that has just passed into the left ventricle from flowing backward.
In mitral valve regurgitation, the mitral valve doesn't close tightly. With each heartbeat, some blood from the left ventricle flows backward into the left atrium instead of moving forward into the aorta. This essentially means that the heart pulls blood backward.
Mitral valve regurgitation causes
Mitral valve regurgitation is classified as primary and secondary. Primary mitral valve regurgitation is caused by an abnormality in the mitral valve. Secondary mitral valve regurgitation is caused by an abnormality in the left ventricle of the heart.
Possible causes of mitral valve regurgitation include:
- Mitral valve prolapse. In this condition, the leaflets and tendon-like cords supporting the mitral valve weaken and stretch so that with each contraction of the left ventricle, the valve leaflets bulge (prolapse) into the left atrium. This common heart defect can prevent the mitral valve from closing tightly and lead to regurgitation.
- Damaged tissue cords. Over time, the tissue cords that anchor the flaps of the mitral valve to the heart wall may stretch or tear, especially in people with mitral valve prolapse. A tear can cause substantial leakage through the mitral valve relatively suddenly and may require repair by heart surgery. Trauma to the chest also can rupture the cords.
- Rheumatic fever. Rheumatic fever — a complication of untreated strep throat and once a common childhood illness in the United States — can damage the mitral valve, leading to mitral valve regurgitation early or later in life. Rheumatic fever is rare in the United States, but still common in developing countries.
- Endocarditis. The mitral valve may be damaged by an infection of the lining of the heart (endocarditis) that can involve heart valves.
- Heart attack. A heart attack can damage the area of the heart muscle that supports the mitral valve, affecting the function of the valve. If the damage is extensive enough, a heart attack can cause sudden and severe mitral valve regurgitation.
- Abnormality of the heart muscle (cardiomyopathy). Over time, certain conditions, such as high blood pressure, can cause your heart to work harder, gradually enlarging your heart's left ventricle. This can stretch the tissue around your mitral valve, which can lead to leakage.
- Trauma. Experiencing trauma, such as in a car accident, can lead to mitral valve regurgitation.
- Congenital heart defects. Some babies are born with defects in their hearts, including damaged heart valves.
- Certain drugs. Prolonged use of certain medications can cause mitral valve regurgitation, such as those containing ergotamine (Cafergot, Migergot) that are used to treat migraines and other conditions.
- Radiation therapy. In rare cases, radiation therapy for cancer that is focused on the chest area can lead to mitral valve regurgitation.
Several factors can increase your risk of mitral valve regurgitation, including:
- A history of mitral valve prolapse or mitral valve stenosis. However, having either condition doesn't necessarily mean you'll develop mitral valve regurgitation. A family history of valve disease also can increase risk.
- A heart attack. A heart attack can damage your heart, affecting the function of the mitral valve.
- Heart disease. Certain forms of heart disease, such as coronary artery disease, can lead to mitral valve regurgitation.
- Use of certain medications. People who take drugs containing ergotamine (Cafergot, Migergot) and similar medicines for migraines and those who took pergolide (now off the market) or who take cabergoline have an increased risk of mitral regurgitation. Similar problems were noted with the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold.
- Infections such as endocarditis or rheumatic fever. Infections or the inflammation they cause can damage the mitral valve.
- Congenital heart disease. Some people are born with an abnormal mitral valve prone to regurgitation.
- Age. By middle age, many people have some mitral valve regurgitation caused by natural deterioration of the valve.
When it's mild, mitral valve regurgitation may not cause problems. However, severe mitral valve regurgitation can lead to these complications:
Heart failure. Heart failure results when your heart can't pump enough blood to meet your body's needs. Severe mitral valve regurgitation places an extra strain on the heart because, with blood pumping backward, there is less blood going forward with each beat. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure.
Also, pressure builds in your lungs, leading to fluid accumulation, which strains the right side of the heart.
- Atrial fibrillation. The stretching and enlargement of your heart's left atrium may lead to this heart rhythm irregularity in which the upper chambers of your heart beat chaotically and rapidly. Atrial fibrillation can cause blood clots, which can break loose from your heart and travel to other parts of your body, causing serious problems, such as a stroke if a clot blocks a blood vessel in your brain.
- Pulmonary hypertension. If you have long-term untreated or improperly treated mitral regurgitation, you can develop a type of high blood pressure that affects the vessels in the lungs (pulmonary hypertension). A leaky mitral valve can increase pressure in the left atrium, which can eventually cause pulmonary hypertension. This can lead to heart failure on the right side of the heart.
Your doctor will ask about your medical history and your family history of heart disease. Your doctor will also perform a physical exam that includes listening to your heart with a stethoscope. Mitral valve regurgitation usually produces a heart murmur, the sound of blood leaking backward through the mitral valve.
Your doctor will then decide which tests are needed to make a diagnosis. For testing, you may be referred to a cardiologist.
Common tests to diagnose mitral valve regurgitation include:
Echocardiogram. This is the test most commonly used to diagnose mitral valve regurgitation. In this test, sound waves directed at your heart from a wandlike device (transducer) held on your chest produce video images of your heart in motion. This test assesses the structure of your heart, the mitral valve and the blood flow through your heart. An echocardiogram helps your doctor get a close look at the mitral valve and how well it's working. Doctors also may use a 3-D echocardiogram.
Doctors may conduct another type of echocardiogram called a transesophageal echocardiogram. In this test, a small transducer attached to the end of a tube is inserted down your esophagus, which allows a closer look at the mitral valve than a regular echocardiogram does. Doctors may also use a 3-D echocardiogram.
- Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on your skin measure electrical impulses from your heart. An ECG can detect enlarged chambers of your heart, heart disease and abnormal heart rhythms.
- Chest X-ray. This enables your doctor to determine whether the left atrium or the left ventricle is enlarged — possible indicators of mitral valve regurgitation — and the condition of your lungs.
- Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create detailed images of your heart. This test may be used to determine the severity of your condition and assess the size and function of your lower left heart chamber (left ventricle).
- Exercise tests or stress tests. Different exercise tests help measure your activity tolerance and monitor your heart's response to physical exertion. If you are unable to exercise, medications to mimic the effect of exercise on your heart may be used.
- Cardiac catheterization. This test isn't often used to diagnose mitral valve regurgitation. This invasive technique involves threading a thin tube (catheter) through a blood vessel in your arm or groin to an artery in your heart and injecting dye through the catheter to make the artery visible on an X-ray. This provides a detailed picture of your heart arteries and how your heart functions. It can also measure the pressure inside the heart chambers.
- CT angiogram. A CT angiogram may be performed of the chest, abdomen and pelvis to determine whether you're a candidate for robotic mitral valve repair.
Mitral valve regurgitation treatment depends on how severe your condition is, if you're experiencing signs and symptoms, and if your condition is getting worse. The goal of treatment is to improve your heart's function while minimizing your signs and symptoms and avoiding future complications.
Some people, especially those with mild regurgitation, might not need treatment. However, the condition may require monitoring by your doctor. You may need regular evaluations, with the frequency depending on how severe your condition is.
Medication can't correct a mitral valve deformity. But medications such as diuretics can relieve fluid accumulation in your lungs or legs, which can accompany mitral valve regurgitation. Blood thinners (anticoagulants), which can help prevent blood clots, may be used if you have atrial fibrillation.
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.
Your mitral valve may need surgical repair, even if it's not causing symptoms. The American College of Cardiology and the American Heart Association recently issued new guidelines for mitral valve surgery, recommending earlier surgery for some people with primary mitral valve regurgitation — caused by an abnormality of the valve — even if they have no symptoms.
Mitral valve surgery should be done at a high-volume mitral valve surgery center with a reputation of excellence and cardiologists, imaging specialists and cardiac surgeons with experience in treating mitral valve conditions.
Discuss the risks and benefits of surgery with your doctor. Your surgery options include:
Valve repair. Mitral valve repair is a surgery that preserves your own valve. For most people with mitral valve regurgitation, repair is preferred to replacement. Surgeons can repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly.
Frequently, repairing the valve includes tightening or reinforcing the ring around the valve (annulus). This is called an annuloplasty. Methods of repairing mitral valves without open-heart surgery are being used in select cases.
Valve replacement. If your mitral valve can't be repaired, your surgeon may replace it with a mechanical or biological valve.
In this procedure, your surgeon replaces the valve by removing the narrowed valve and replacing it with a mechanical or biological tissue (bioprosthetic) valve. Mechanical valves, made from metal, are durable but carry the risk of blood clots forming. If you receive a mechanical mitral valve, you'll need to take an anticoagulant medication, such as warfarin (Coumadin, Jantoven), for life to prevent blood clots.
Biological tissue valves — which may come from a pig, cow or human deceased donor — eventually need to be replaced, as they degenerate over time, particularly rapidly in younger people. Your doctor can discuss the risks and benefits of each type of heart valve with you.
If you have another condition such as coronary artery disease or atrial fibrillation, doctors may treat this at the same time your mitral valve is repaired or replaced.
Talk to your doctor about what type of follow-up you need after surgery, and let your doctor know if you develop new symptoms or if your symptoms worsen after treatment.
Less invasive procedures
Mitral valve repair or replacement generally requires open-heart surgery. Less invasive surgical techniques and procedures are being explored for mitral valve surgery and are available at some medical centers. Minimally invasive surgery should only be performed by a team of surgeons and other specialists experienced in conducting this type of procedure.
Minimally invasive heart surgery
Mitral valve repair may be conducted using minimally invasive heart surgery. Minimally invasive heart surgery is conducted through one or several small incisions in your chest. Surgical techniques include:
Robot-assisted heart surgery. In robot-assisted heart surgery, a surgeon uses robotic arms to duplicate specific maneuvers used in open-heart surgeries to conduct mitral valve repair.
In this procedure, your surgeon sits at a remote console and views your heart in a magnified high-definition 3-D view on a video monitor. Your surgeon's hand movements are translated precisely to the robotic arms at the operating table, which move like a human wrist. At the operating table, a surgical team assists with the procedure and changes the surgical instruments attached to the robotic arms.
- Thoracoscopic surgery. In thoracoscopic surgery, your surgeon inserts a long, thin tube (thoracoscope) containing a tiny high-definition video camera into a small incision in your chest. Your surgeon conducts the procedure using long instruments inserted through small incisions between your ribs.
- Ministernotomy. In a ministernotomy, a small incision is made through the breastbone. Sometimes particular factors indicate that accessing the heart this way is the safer way to repair or replace the mitral valve.
Minimally invasive heart surgery is associated with less pain, a shorter hospital stay and fewer complications. However, the surgery is appropriate only in certain circumstances. Talk to your surgeon to see if this type of surgery might be right for you.
Several procedures using long thin tubes (catheters) to repair or replace the mitral valve have been studied and are available at some medical centers.
In one approach, an implantable clip is used to repair the mitral valve. In another procedure, doctors may use catheters to repair a leaking mechanical or bioprosthetic valve that has previously been implanted to replace the mitral valve. In this procedure, doctors insert a device into the leaking area to plug the leak.
If your bioprosthetic replacement valve is no longer working, doctors may conduct a catheter procedure to replace the valve. In this procedure, doctors insert a catheter with a balloon at the end into a blood vessel in your leg and thread it to the heart using imaging. A replacement valve is inserted in the catheter and guided to the heart. Doctors inflate the balloon in the bioprosthetic valve, and place the replacement valve inside the bioprosthetic valve. The replacement valve is then expanded.
If you think you have mitral valve regurgitation, make an appointment to see your doctor. Here's some information to help you prepare for your appointment.
What you can do
- Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do beforehand.
- Write down your symptoms, including any that seem unrelated to mitral valve regurgitation.
- Write down key personal information, including a family history of heart disease, heart defects, genetic disorders, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
- Make a list of all medications, vitamins and supplements you take.
- Take a family member or friend along, if possible. Someone who accompanies you can help you remember information you receive.
- Be prepared to discuss your diet and exercise habits. If you don't already eat well and exercise, be ready to talk to your doctor about challenges you might face in getting started.
- Write down questions to ask your doctor.
For mitral valve regurgitation, some basic questions to ask your doctor include:
- What is likely causing my symptoms or condition?
- What are other possible causes for my symptoms or condition?
- What tests will I need?
- What's the best treatment?
- What are the alternatives to the primary approach you're suggesting?
- I have other health conditions. How can I best manage them together?
- Are there restrictions I need to follow?
- Should I see a specialist?
- If I need surgery, which surgeon do you recommend for mitral valve repair?
- Is there a generic alternative to the medicine you're prescribing?
- Are there brochures or other printed material I can take with me? What websites do you recommend?
Don't hesitate to ask other questions you have.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, including:
- When did your symptoms begin?
- Have your symptoms been continuous or occasional?
- How severe are your symptoms?
- What, if anything, seems to improve your symptoms?
- What, if anything, appears to worsen your symptoms?
To improve your quality of life, your doctor may recommend that you:
- Keep your blood pressure under control. Control of high blood pressure is important if you have mitral valve regurgitation.
- Eat a heart-healthy diet. Food doesn't directly affect mitral valve regurgitation. But a healthy diet can help prevent other heart disease that can weaken the heart muscle. Eat foods that are low in saturated and trans fats, sugar, salt, and refined grains, such as white bread. Eat a variety of vegetables and fruits, whole grains, and proteins, such as lean meats, fish and nuts.
- Maintain a healthy weight. Keep your weight within a range recommended by your doctor.
- Prevent infective endocarditis. If you have had a heart valve replaced, your doctor may recommend you take antibiotics before dental procedures to prevent an infection called infective endocarditis. Check with your doctor to find out if he or she recommends that you take antibiotics before dental procedures.
- Cut back on alcohol. Heavy alcohol use can cause arrhythmias and can make your symptoms worse. Excessive alcohol use can also cause cardiomyopathy, a condition of weakened heart muscle that leads to mitral regurgitation. Ask your doctor about the effects of drinking alcohol.
- Exercise. How long and hard you're able to exercise depends on the severity of your condition and the intensity of exercise. Ask your doctor for guidance before starting to exercise, especially if you're considering competitive sports.
- See your doctor regularly. Establish a regular evaluation schedule with your cardiologist or primary care provider. Tell your doctor if you have any changes in your signs or symptoms.
If you're a woman with mitral valve regurgitation, discuss family planning with your doctor before you become pregnant. Pregnancy causes the heart to work harder. How a heart with mitral valve regurgitation tolerates this extra work depends on the degree of regurgitation and how well your heart pumps. Throughout your pregnancy and after delivery, your cardiologist and obstetrician should monitor you.
If you have mitral valve regurgitation, here are some steps that may help you cope:
- Take medications as prescribed. Take your medications as directed by your doctor.
- Get support. Having support from your family and friends can help you cope with your condition. Ask your doctor about support groups that may be helpful.
- Stay active. It's a good idea to stay physically active. Your doctor may give you recommendations about how much and what type of exercise is appropriate for you.