1. Zoll Firm Lecture Series
Mitral regurgitation
2008
Zoll Firm Lecture Series

2. Valvular regurgitation: P ~ V relationship
2008
Zoll Firm Lecture Series

3. Normal mitral valve apparatus
2008
Zoll Firm Lecture Series

4. Zoll Firm Lecture Series
2008
Zoll Firm Lecture Series

5. Zoll Firm Lecture Series
2008
Zoll Firm Lecture Series

6. Zoll Firm Lecture Series
2008
Zoll Firm Lecture Series

7. Zoll Firm Lecture Series
2008
Zoll Firm Lecture Series

8. Zoll Firm Lecture Series
2008
Zoll Firm Lecture Series

9. Acute mitral regurgitation
Papillary muscle rupture
Acute MI
Chordal rupture
Pre-existing MVP
Valve perforation
Infectious endocarditis
History consistent with ACS hours earlier
Q waves on ECG
Regional WMAs on echo
Valve leaflets intact
history of MVP
younger person
no WMA on echo
pap muscle intact on echo
fevers, systemic symptoms
history of predisposition to IE
perforated leaflet on echo
must rule out involvement of other valves
Acute heart failure  cardiogenic shock
2008
Zoll Firm Lecture Series

10. Papillary muscle rupture
2008
Zoll Firm Lecture Series

11. Acute mitral regurgitation
Must involve cardiac surgery early
Intraaortic balloon pump used for immediate afterload reduction
Until IABP available
Nitroprusside IV
Dobutamine IV
2008
Zoll Firm Lecture Series

12. Chronic mitral regurgitation
2008
Zoll Firm Lecture Series

13. Chronic (greater than mild) mitral regurgitation
Organic (primary)
Valve abnormal LV normal at first
Secondary
Valve normal LV abnormal
MVP
isolated
connective tissue d/o
rheumatic
congenital
endocarditis sequelae
anorectic drugs
Kawasaki disease
Dilated annulus
dilated cardiomyopathy
old infarction
Abnormal valve motion
papillary muscle dysfxn
hypertrophic myopathy
No Sx Atrial arrhythmias PHTN Heart failure (SC)death
2008
Zoll Firm Lecture Series

14. Zoll Firm Lecture Series
Mitral valve prolapse
Myxomatous / redundant mitral leaflets
Malcoaptation of leaflet tips
Most without significant regurgitation
Tendency for overdiagnosis (1980’s)
2008
Zoll Firm Lecture Series

15. Myxomatous mitral valve disease / MVP
2008
Zoll Firm Lecture Series

16. MR: Selection of patients for surgical therapy
2008
Zoll Firm Lecture Series

17. Why not necessarily wait until symptoms?
Once severe MR is symptomatic, mortality is >20% per year
Surgery alleviates symptoms and improves prognosis BUT
Surgery does NOT normalize life expectancy in symptomatic patients
2008
Zoll Firm Lecture Series

18. Severe MR: symptomatic patients
Symptoms attributable to severe MR
MVR
2008
Zoll Firm Lecture Series

19. Dilemma in asymptomatic patients
Early surgery
Alleviation of symptoms Improvement in survival Reduction in disease
progression
Improvement in surgical methodology
Longer-lasting bioprostheses (15-20 years) Intrinsic abnormalities of valve tissue raise questions re: durability of valve repair
Medical therapy
No operative morbidity
Delay 1st operation, potentially avoid need for reoperation
Avoid embolic and bleeding complications of prosthetic valves Drugs do not work ** Intrinsic LV dysfunction not always apparent **
2008
Zoll Firm Lecture Series

20. Medical management of mitral regurgitation
Afterload reduction ”makes sense” physiologically
Acute IV vasodilation (nitroprusside)  regurgitant volume ↓
Chronic vasodilation (ACE-I, ARB, hydralazine)  modest change
None of the studies demonstrate a reliable benefit in all patients over the long-term
2008
Zoll Firm Lecture Series

21. Medical management of mitral regurgitation
Start afterload reduction (usually ACE-I) in:
Anyone with another reason for afterload reduction (cardiomyopathy, HTN)
Anyone with a specific indication for a specific drug (e.g., ACE-I)
Pt with severe MR who is not a surgical candidate
Empiric drug choice in mitral regurgitation
CAD, nonischemic myopathy: ACE-I + nitrate
MVP with MR – ?avoid pure preload reduction with a decrease in chamber size  beta-blocker + thiazide (careful if diabetic)
Rheumatic MR: BB, thiazide, CaChB
2008
Zoll Firm Lecture Series

22. Severe MR: asymptomatic patients
LVEF < 60%
LVEDD ≥45 mm
Persistent AF
Depressed RV function
Pulmonary HTN
Definite MVR
Strongly consider MVR
Decreasing RVEF
Paroxysmal AF
2008
Zoll Firm Lecture Series

23. MR: Selection of patients for surgical therapy
2008
Zoll Firm Lecture Series

24. MR: Selection of patients for surgical therapy
Enrique-Sarano et al., NEJM 2005
2008
Zoll Firm Lecture Series

25. Enriquez-Sarano, et al. Circulation 1995
MVR with CABG
Enriquez-Sarano, et al. Circulation 1995
2008
Zoll Firm Lecture Series

26. Zoll Firm Lecture Series
Take home points
Consider acute MR in all cases of acute heart failure, especially if patients are young, have no prior cardiac disease, or have endocarditis / ACS
Search for chronic MR
Use antibiotic prophylaxis if MR is greater than mild (pause to think when you get an echo report back with 2+MR)
Look for a reason to start afterload reduction
Refer to a cardiologist early on
Be aggressive with surgical referrals in young patients with MVP and severe MR
2008
Zoll Firm Lecture Series