Mitral Valve Regurgitation

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What is Mitral Valve Regurgitation

Mitral valve regurgitation, also called mitral regurgitation, is a condition in which blood leaks from the mitral valve in the heart.

The mitral valve is located between the upper left chamber (left atrium) and the lower left chamber (left ventricle) of the heart. Normally, this valve opens when the atrium pumps blood into the ventricle, and it closes when the ventricle pumps blood out to the body.

Mitral valve regurgitation happens when the mitral valve does not close properly. As a result, blood in the ventricle leaks back into the atrium.

Mitral valve regurgitation causes the heart to work harder to pump blood. If the condition is mild, a person may not have symptoms. However, over time, this can lead to heart failure.

12 Interesting Facts of Mitral Valve Regurgitation

Mitral valve regurgitation is backflow of blood from the left ventricle to the left atrium during ventricular contraction caused by structural or functional mitral valve abnormalities; may lead to increased left atrial pressure, left ventricle dilation and dysfunction, and left ventricle failure
Acute mitral valve regurgitation may be caused by papillary muscle rupture after acute myocardial infarction or rupture of chordae tendineae or perforation of valve leaflets in infectious endocarditis; can result from cardiac trauma
Chronic, primary mitral valve regurgitation is caused by degenerative or structural abnormalities of the mitral valve, most commonly mitral valve prolapse; other causes include infectious endocarditis, rheumatic mitral valve disease, radiation heart disease, and connective tissue diseases
In chronic, secondary mitral regurgitation, the mitral valve is structurally normal, and regurgitation is caused by left ventricle dysfunction associated with ischemia or other myocardial disease
Diagnosed based on cardiac auscultation and echocardiography; additional tests may be indicated to evaluate for arrhythmias or underlying ischemic heart disease, or if echocardiography provides inadequate information
Mild to moderate chronic mitral regurgitation is often asymptomatic; however, acute or severe cases may result in signs and symptoms of heart failure
Classic murmur associated with mitral regurgitation is a blowing high-pitched holosystolic murmur loudest at apex and radiating to the axilla
Echocardiography establishes diagnosis, cause, and hemodynamic severity of mitral regurgitation and effect on left ventricle size and function
Treatment of chronic, primary mitral regurgitation depends on symptoms, severity of mitral regurgitation, and hemodynamic consequences
- Most asymptomatic patients with mild mitral regurgitation can be managed conservatively, whereas mitral valve surgery is indicated in patients with symptomatic, severe mitral regurgitation; left ventricle dysfunction; or progressive symptoms
Treatment of chronic, secondary mitral regurgitation primarily consists of standard guideline-directed medical therapy for underlying heart failure and/or ischemic heart disease
Acute mitral valve regurgitation is a medical emergency requiring hemodynamic support and urgent mitral valve surgery
Mitral valve repair is the preferred procedure in most cases as it is associated with improved outcomes when compared with valve replacement

What are the causes?

Mitral valve regurgitation may be caused by:

A condition in which the mitral valves do not close completely when the heart pumps blood (mitral valve prolapse).
Infection, such as endocarditis or rheumatic fever.
Damage to the mitral valve, such as from injury (trauma) to the heart, a problem present at birth (birth defect), or a heart attack.
Certain medicines.

What increases the risk?

Mitral valve regurgitation is more likely to develop in people who have:

Certain forms of heart disease.
A family history of heart valve disease.
Certain conditions that are present at birth (congenital).

You are also more likely to develop this condition if you have taken certain diet pills in the past.

What are the symptoms of Mitral valve regurgitation?

Symptoms of Mitral valve regurgitation include:

Shortness of breath with physical activity, like climbing stairs.
Fast or irregular heartbeat.
Cough.
Suddenly waking up at night with difficulty breathing or needing to urinate.
Heavy breathing.
Extreme tiredness.
Swelling in the lower legs, ankles, and feet.

In some cases of mild to moderate mitral regurgitation, there are no symptoms.

How is Mitral valve regurgitation diagnosed?

This condition may be diagnosed based on the results of a physical exam. Your health care provider will listen to your heart for an abnormal heart sound (murmur). You may also have other tests, including:

An echocardiogram. This test creates ultrasound images of the heart that allow your health care provider to see how the heart valves work while your heart is beating.
Chest X-ray.
Electrocardiogram (ECG). This is a test that records the electrical impulses of the heart.
Cardiac catheterization. This test is used to look at the structure and function of the heart. A thin tube (catheter) is passed through the blood vessels and into the heart. Dye is injected into the blood vessels so the cardiac system can be seen on images that are taken.

How is this treated?

Mitral valve regurgitation may be treated with:

Medicines. These may be given to treat symptoms and prevent complications.
Surgery to repair or replace the mitral valve in severe, long-term (chronic) cases.

Follow these instructions at home:

Lifestyle

Limit alcohol intake to no more than 1 drink a day for nonpregnant women and 2 drinks a day for men. One drink equals 12 oz of beer, 5 oz of wine, or 1½ oz of hard liquor.
Do not use any products that contain nicotine or tobacco, such as cigarettes and e-cigarettes. If you need help quitting, ask your health care provider.
Eat a heart-healthy diet that includes plenty of fresh fruits and vegetables, whole grains, low-fat (lean) protein, and low-fat dairy products. Consider working with a diet and nutrition specialist (dietitian) to help you make healthy food choices.
Limit the amount of salt (sodium) in your diet. Avoid adding salt to foods, and avoid foods that are high in salt, such as:
- Pickles.
- Smoked and cured meats.
- Processed foods.
Maintain a healthy weight and stay physically active. Ask your health care provider to recommend activities that are safe for you.
Try to get 7 or more hours of sleep each night.
Find ways to manage stress. If you need help with this, ask your health care provider.

General instructions

Take over-the-counter and prescription medicines only as told by your health care provider.
Work closely with your health care provider to manage any other health conditions you have, such as diabetes or high blood pressure.
If you plan to become pregnant, talk with your health care provider first.
Keep all follow-up visits as told by your health care provider. This is important.

Contact a health care provider if:

You have a fever.
You feel more tired than usual when doing physical activity.
You have a dry cough.

Get help right away if:

You have shortness of breath.
You develop chest pain.
You have swelling in your hands, feet, ankles, or abdomen that is getting worse.
You have trouble staying awake or you faint.
You feel dizzy or unsteady.
You suddenly gain weight.
You feel confused.
Any of your symptoms begin to get worse.

These symptoms may represent a serious problem that is an emergency. Do not wait to see if the symptoms will go away. Get medical help right away. Call your local emergency services (911 in the U.S.). Do not drive yourself to the hospital.

Additional Info on Mitral valve regurgitation

Mitral valve regurgitation is a common form of valvular heart disease characterized by backflow of blood from the left ventricle to the left atrium during ventricular contraction

Can be caused by a variety of structural or functional mitral valve abnormalities and may result in increased left atrial pressure, left ventricle dilation and dysfunction, and left ventricle failure

Classification

Chronic mitral valve regurgitation
- In the United States, most prevalent valvular lesion in the adult population
- Further categorized by underlying cause
  - Primary (degenerative)
    - Mitral regurgitation is caused by degenerative or structural abnormalities of mitral valve components
    - Most commonly caused by mitral valve prolapse; other causes include infectious endocarditis, rheumatic mitral valve disease, radiation heart disease, and connective tissue diseases (Related: Mitral valve prolapse)
    - Severity
      - Stage A (at risk of developing mitral regurgitation)
        Asymptomatic
        Mild abnormalities of mitral valve structure or function (mild mitral valve prolapse with normal coaptation)
        No hemodynamic effects
      - Stage B (progressive mitral regurgitation)
        Asymptomatic
        More severe valvular abnormalities (severe mitral valve prolapse with normal coaptation)
        Mild enlargement of left atrium; no enlargement of left ventricle
        Pulmonary pressure within reference range
      - Stage C (asymptomatic severe mitral regurgitation)
        Asymptomatic
        Severe mitral valve prolapse with loss of coaptation or flail leaflet
        Severe mitral regurgitation based on assessment of several echocardiographic parameters
        Left atrial and left ventricular enlargement
        Pulmonary hypertension may be present
        Subgroups
        Stage C1: not associated with left ventricle dysfunction (left ventricle end systolic diameter less than 40 mm and left ventricle ejection fraction greater than 60%)
        Stage C2: associated with left ventricle dysfunction (left ventricle end systolic diameter of 40 mm or larger and left ventricle ejection fraction of 60% or less)
      - Stage D (symptomatic severe mitral regurgitation)
        Symptomatic
        Severe mitral valve prolapse with loss of coaptation or flail leaflet
        Severe mitral regurgitation based on assessment of several echocardiographic parameters
        Left atrial and left ventricular enlargement
        Pulmonary hypertension
  - Secondary (functional)
    - Most common cause of mitral regurgitation
    - Mitral regurgitation is caused by left ventricle dysfunction associated with ischemia or other myocardial disease
    - Mitral valve chords and leaflets are usually structurally normal but loss of coaptation occurs because of left ventricle dilation and papillary muscle displacement
    - Subcategorized as ischemic (associated with coronary artery disease or post–myocardial infarction remodeling) or nonischemic (associated with left ventricle dilation due to cardiomyopathy)
    - Severity
      - Stage A (at risk of developing mitral regurgitation)
        Symptoms due to heart failure or ischemia that respond to medical therapy or revascularization may be present
        Normal or mildly dilated left ventricle size with fixed or inducible regional wall motion abnormalities; primary myocardial disease with left ventricle dilation and systolic dysfunction
        Normal mitral valve structure
      - Stage B (progressive mitral regurgitation)
        Symptoms due to heart failure or ischemia that respond to medical therapy or revascularization may be present
        Left ventricle dilation and impaired left ventricle systolic function due to myocardial disease
        Regional left ventricle wall motion abnormalities with reduced left ventricle systolic function; left ventricle dilation and systolic dysfunction due to primary myocardial disease
        Regional wall motion abnormalities with mild tethering of mitral valve leaflet; annular dilation with mild loss of coaptation of mitral valve leaflets
      - Stage C (asymptomatic severe mitral regurgitation)
        Symptoms due to heart failure or ischemia that respond to medical therapy or revascularization may be present
        Regional wall motion abnormalities with reduced left ventricle systolic function; left ventricle dilation and impaired left ventricle systolic function due to primary myocardial disease
        Regional wall motion abnormalities and/or left ventricle dilation and severe tethering of mitral valve leaflet; annular dilation with severe loss of coaptation of mitral valve leaflets
      - Stage D (symptomatic severe mitral regurgitation)
        Symptoms of heart failure due to mitral regurgitation are refractory to optimal medical therapy or revascularization; exertional dyspnea and reduced exercise tolerance
        Regional wall motion abnormalities with reduced left ventricle systolic function; left ventricle dilation and systolic dysfunction due to primary myocardial disease and severe tethering of mitral valve leaflet
        Regional wall motion abnormalities and/or left ventricle dilation with severe tethering of mitral valve leaflet; annular dilation with severe loss of coaptation of mitral valve leaflets
Acute mitral valve regurgitation
- Rare medical emergency requiring urgent intervention
- Sudden onset of symptomatic mitral regurgitation after rupture of papillary muscle or chordae tendineae or perforation of valve leaflets
- May occur in context of infectious endocarditis or acute myocardial infarction

Clinical Presentation

History

Chronic mitral valve regurgitation
- Gradual onset over several years; variable in severity and may or may not be symptomatic
- Asymptomatic in mild to moderate cases
- Severe mitral regurgitation may result in the following:
  - Dyspnea (at rest or on exertion)
  - Orthopnea
  - Paroxysmal nocturnal dyspnea
  - Reduced exercise tolerance
  - Palpitations
  - Fatigue
  - Ankle swelling
Acute mitral valve regurgitation may present with collapse due to cardiogenic shock

Physical examination

Atrial fibrillation is a common finding in long-standing chronic mitral regurgitation and acute mitral regurgitation
Patients with acute severe mitral valve regurgitation may be hypotensive
Findings suggestive of volume overload may be present, including:
- Tachypnea and tachycardia
- Cool extremities
- Crackles, rales, or wheezes
- Peripheral edema
- Jugular venous distention
Palpation of chest may demonstrate lateral displacement of the apical impulse owing to left ventricle enlargement and hyperdynamic apical impulse
- A precordial thrill may be detected in acute or severe mitral regurgitation
Auscultation typically reveals a blowing high-pitched systolic murmur, loudest at apex and radiating to the axilla
- Classic murmur is holosystolic; presence suggests more severe regurgitation. Generally, murmur intensity also correlates with severity
  - May occur in late systole with less severe regurgitation
  - May be atypical, absent, or quiet in acute severe mitral regurgitation
- Presence of S₃ suggests acute or severe mitral regurgitation
- S₁ may be diminished
Dynamic auscultation may produce variation in murmur intensity
- Intensity is increased with squatting, leg raises, or isometric handgrip
- Intensity is decreased with standing or Valsalva maneuver

Causes of Mitral valve regurgitation

Can be result of a variety of structural or functional mitral valve abnormalities
Chronic mitral regurgitation
- May be caused by degenerative or structural abnormalities of the mitral valve components or by left ventricle dysfunction associated with ischemia or other myocardial disease
- Chronic mitral regurgitation is most commonly caused by mitral valve prolapse; other causes include infectious endocarditis, rheumatic mitral valve disease, radiation heart disease, and connective tissue diseases (Related: Mitral valve prolapse)primary
- In chronic secondary mitral valve regurgitation, the mitral valve itself is structurally normal and mitral regurgitation is caused by left ventricle dysfunction associated with ischemia or other myocardial disease; the resulting left ventricle dilation causes displacement of the papillary muscles and impaired mitral valve closure
Acute mitral regurgitation
- May be caused by papillary muscle rupture after acute myocardial infarction or rupture of chordae tendineae or perforation of valve leaflets in infectious endocarditis; can also result from cardiac trauma

Risk factors and/or associations

Age

Prevalence increases with advancing age, ranging from 18% in adults younger than 55 years to 22% to 27% in adults aged 65 to 74 years

Sex

Prevalence in males and females is similar

Other risk factors/associations

Mitral valve prolapse
Rheumatic heart disease
Infectious endocarditis
Myocardial infarction
Ischemic heart disease
Hypertrophic cardiomyopathy
Left ventricle systolic dysfunction
History of radiation therapy
Hypertension
Renal dysfunction
Mitral stenosis
Lower BMI

Diagnostic Procedures

Primary diagnostic tools

Diagnose mitral valve regurgitation based on cardiac auscultation and echocardiography; may be an incidental finding
Additional tests may be indicated to evaluate for arrhythmias or underlying ischemic heart disease, or if echocardiography provides inadequate or inconsistent information
- May include cardiac catheterization, stress echocardiography, transesophageal echocardiography, or cardiovascular magnetic resonance
- Cardiac catheterization or CT angiography is indicated before undertaking valve intervention in patients with suspected coronary artery disease, risk factors for coronary artery disease, or reduced left ventricle function, and in all patients with severe secondary mitral regurgitation
Multimodality imaging may be useful for determining eligibility for mitral procedures (repair or replacement), preinterventional planning, and periprocedural guidance

Imaging

Echocardiography
- Recommended for all patients to diagnose mitral valve regurgitation, determine cause, and evaluate hemodynamic severity of regurgitation and left ventricle size and function
- Transthoracic echocardiography is diagnostic in most cases; transesophageal echocardiography may be necessary if transthoracic image quality is inadequate
- Doppler flow measurement is used to quantify severity of mitral regurgitation

Mitral Valve regurgitation severity:*	Mild	Moderate	Severe
Mitral valve morphology	None or mild leaflet abnormality (eg, mild thickening, calcifications, or prolapse; mild tenting)	Moderate leaflet abnormality or moderate tenting	Severe valve lesions (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
Left ventricle and left atrium size†	Usually normal	Normal or mild dilated	Dilated‡
Color flow jet area§	Small, central, narrow, often brief	Variable	Large central jet (more than 50% of left atrium) or eccentric wall-impinging jet of variable size
Flow convergence**	Not visible, transient or small	Intermediate in size and duration	Large through systole
Continuous wave Doppler jet	Faint/partial/parabolic	Dense but partial or parabolic	Holosystolic/dense/triangular
VCW (cm)	Less than 0.3	Intermediate	0.7 or greater (more than 0.8 for biplane)††
Pulmonary vein flow‡‡	Systolic dominance (may be blunted in left ventricle dysfunction or atrial fibrillation)	Normal or systolic blunting‡‡	Minimal to no systolic flow/systolic flow reversal
Mitral inflow§§	A-wave dominant	Variable	E-wave dominant (greater than 1.2 m/second)
Effective regurgitant orifice area, 2-dimensional proximal isovelocity surface area (cm²)	Less than 0.20	0.20 to 0.290.30 to 0.39	0.40 or greater (may be lower in secondary mitral regurgitation with elliptical regurgitant orifice area)
Regurgitant volume (mL)	Less than 30	30 to 4445 to 59***	60 or greater (may be lower in low-flow conditions)
Regurgitant fraction (%)	Less than 30	30 to 3940 to 49	50 or greater

Caption: *All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body, size, sex, and all other patient characteristics. †This pertains mostly to patients with primary mitral regurgitation. ‡Left ventricle and left atrium can be within the “normal” range for patients with acute severe mitral regurgitation or with chronic severe mitral regurgitation who have small body size, particularly women, or with small left ventricle size preceding the occurrence of mitral regurgitation. §With Nyquist limit 50 to 70 cm/second. **Small flow convergence is usually less than 0.3 cm, and large is 1 cm or greater at a Nyquist limit of 30 to 40 cm/second. ††For average between apical 2- and 4-chamber views. ‡‡Influenced by many other factors (left ventricle diastolic function, atrial fibrillation, left atrium pressure). §§Most valid in patients older than 50 years and is influenced by other causes of elevated left atrium pressure. ***Discrepancies among effective regurgitant orifice area, regurgitant fraction, and regurgitant volume may arise in the setting of low- or high-flow states. †††Quantitative parameters can help subclassify the moderate regurgitation group.

Citation: From Zoghbi WA et al: Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 30(4):303-71, 2017, Table 8.

3-dimensional transesophageal techniques may aid in delineating mitral valve anatomy and guiding valve repair; used preoperatively, intraoperatively, and in percutaneous valve interventions

Functional testing of Mitral valve regurgitation

ECG
- Not required for diagnosis but routinely performed in all patients
- May demonstrate associated arrhythmias (eg, atrial fibrillation) or evidence of left atrial enlargement
Stress testing
- May be indicated in patients with chronic primary mitral regurgitation to assess symptoms, functional capacity, and exercise-induced hemodynamic changes, particularly when there is a discrepancy between reported symptoms and severity of mitral regurgitation on tests performed at rest

Differential Diagnosis

Most common

Chronic obstructive pulmonary disease
Heart Failure
Aortic Valve Stenosis
Tricuspid regurgitation

Treatment Goals of Mitral valve regurgitation

Minimize hemodynamic consequences of mitral regurgitation
Repair causative mitral valve abnormality

Admission criteria

Admit for surgical or percutaneous treatment of mitral regurgitation, if intervention is indicated

Criteria for ICU admission

Postoperatively after valvular surgery

Recommendations for specialist referral

Refer to cardiologist if echocardiography shows significant or progressive mitral regurgitation
Refer to cardiothoracic surgeon for valvular surgery if needed for patients who have severe or progressive symptoms, or severe mitral regurgitation

Treatment Options

Acute mitral valve regurgitation

Medical emergency requiring urgent mitral valve surgery
May require IV vasodilators (eg, sodium nitroprusside, nicardipine), intra-aortic balloon counterpulsation, or mechanical circulatory support to stabilize hemodynamic status before surgery

Chronic primary mitral regurgitation

Asymptomatic patients
- Most asymptomatic patients with mild mitral regurgitation can be managed conservatively with monitoring and counseling on healthy lifestyle and regular exercise
  - No drugs or other therapies are needed
  - Antibiotic prophylaxis for infectious endocarditis is not recommended unless patient has had a history of known endocarditis
  - Antiplatelet therapy or anticoagulation is not required unless patient has other indications (eg, history of transient ischemic attack or stroke, concomitant atrial fibrillation)
- Surgical intervention is recommended for asymptomatic patients with severe mitral regurgitation in the presence of impaired left ventricle systolic function (stage C2)
- Surgery is reasonable for asymptomatic patients who meet all of the following criteria:
  - Chronic severe primary mitral regurgitation (stage C1)
  - Preserved left ventricle function (left ventricle ejection fraction greater than 60% and left ventricle end-systolic dimension less than 40 mm)
  - Progressive increase in left ventricle size or decrease in ejection fraction on serial imaging studies
  - Likelihood of successful repair greater than 95% and expected mortality rate less than 1% when performed at a heart valve center of excellence
Symptomatic patients
- Symptomatic patients with severe primary mitral regurgitation (stage D), impaired left ventricle systolic function, or severe or progressive symptoms generally require surgical intervention
- Surgery is also considered reasonable in the absence of left ventricle dysfunction/dilation (stage C1) if there is a high likelihood of a successful and durable repair, and expected mortality is less than 1%
- (Related: Heart failure)Treat patients with symptomatic primary mitral regurgitation (stage D) and impaired systolic function with standard regimen for heart failure if surgery is not feasible or will be delayed; β-adrenergic blockers and ACE inhibitors have best evidence for benefit

Chronic secondary mitral valve regurgitation

Surgical correction of mitral regurgitation is less likely to be successful
Treat patients with secondary mitral regurgitation using standard guideline-directed medical therapy for underlying heart failure and/or ischemic heart disease (Related: Heart failure)
- Coronary revascularization or cardiac resynchronization therapy may also be indicated (Related: Stable ischemic heart disease)
Patients with severe secondary mitral regurgitation (stage D) who remain severely symptomatic despite optimal medical therapy may be considered for mitral valve surgery
- Surgical intervention can also be considered for patients with moderate or severe secondary mitral regurgitation (stage C or D) who are undergoing other cardiac surgery (eg, coronary artery bypass grafting)
Patients with severely impaired left ventricle function refractory to heart failure treatment may require implantation of a mechanical circulatory assist device or heart transplantation

Therapeutic options

Mitral valve repair is the gold standard for treatment of significant mitral regurgitation
- Associated with lower perioperative mortality and better preservation of left ventricle function compared with mitral valve replacement and avoids risks (eg, thromboembolic events, anticoagulation) associated with prosthetic heart valves
- May be performed via open cardiac surgery, minimally invasive approach, or percutaneous catheter
  - Surgical repair is the main approach for primary mitral regurgitation
    - Minimally invasive or robotic techniques are used in over 10% of cases
  - Percutaneous transcatheter mitral valve repair has a limited role in treatment of primary mitral regurgitation at present
    - Currently the only system approved by the FDA is edge-to-edge mitral leaflet coaptation using a clip; other repair systems are being developed
    - Primarily reserved for patients with severe symptomatic mitral regurgitation who are poor candidates for surgery
    - Used more widely outside the United States
Mitral valve replacement is considered the second-choice procedure
- May be preferable over valve repair in selected patients, including those with prior cardiac surgery or chest irradiation, and those with Carpentier type I or IIIa valve morphologies (eg, due to endocarditis or rheumatic heart disease) if otherwise unrepairable
- In patients with secondary mitral regurgitation (eg, due to ischemic heart disease), mitral valve repair is associated with similar long-term survival, functional outcomes, and replacement. Perioperative mortality is higher; however, there is a lower rate of recurrent regurgitation
- Mechanical mitral valves may be preferred owing to lower mortality and lower risk of reoperation compared with biologic valves; however, mechanical valves require lifelong anticoagulation and are associated with a higher risk of bleeding. Choice of valve should consider age of the patient and suitability for anticoagulation
- May be performed by open surgical or minimally invasive approach

Drug therapy

Vasodilators
- Sodium nitroprusside
  - Sodium Nitroprusside Solution for injection; Adults: Initially, 0.25 to 0.3 mcg/kg/minute IV. Max: 10 mcg/kg/minute for 10 minutes.
- Nicardipine
  - Nicardipine Hydrochloride Solution for injection; Adults: Initially, 5 mg/hour continuous IV infusion. If needed, increase infusion rate by 2.5 mg/hour every 5—15 minutes, up to a temporary max of 15 mg/hour. As soon as BP goal is achieved, decrease rate to 3 mg/hour IV.
β-adrenergic blockers
- Metoprolol
  - Metoprolol Tartrate Oral tablet; Adults: A target dose of 100 to 200 mg/day PO has been studied; a starting dose of 12.5 mg/day has been used; dose should be titrated to target as tolerated.
- Carvedilol
  - Carvedilol Oral tablet; Adults: Initially, 3.125 mg PO twice daily for 2 weeks. Increase dosage to 6.25, 12.5, and then 25 mg PO twice daily over intervals of at least 2 weeks as tolerated. Max: 50 mg PO twice daily. Reduce dose for bradycardia.
ACE inhibitors
- Enalapril
  - Enalapril Maleate Oral tablet; Adults: Initially, 2.5 mg PO twice daily. Reduce initial dose to 2.5 mg PO once daily in patients with hyponatremia. Increase dose as tolerated, adjusting to clinical response of patient up to Max: 10 to 20 mg PO twice daily.
- Lisinopril
  - Lisinopril Oral tablet; Adults: Initially, 2.5 to 5 mg PO once daily. Increase dose as tolerated, adjusting to clinical response of patient up to Max: 20 to 40 mg/day.

Nondrug and supportive care

Procedures

Mitral valve repair

General explanation

Procedure of choice whenever possible; may be performed via open cardiac surgery, minimally invasive approach, or percutaneous catheter
A variety of techniques may be used, including leaflet resection, plication, artificial chords, and leaflet reduction (eg, sliding plasty for posterior leaflet, annuloplasty band or ring)
Transcatheter repair may be considered for patients with severe mitral regurgitation who are severely symptomatic despite optimal medical therapy and who have prohibitive surgical risk because of severe comorbidities, providing they have favorable anatomy for the repair procedure and a reasonable life expectancy

Indication

Symptomatic patients with severe, acute, primary mitral regurgitation
Symptomatic patients with severe, chronic, primary mitral regurgitation; impaired left ventricle systolic function; or severe or progressive symptoms
Asymptomatic patients with severe, chronic, primary mitral regurgitation in the presence of impaired left ventricle systolic function
- Also considered reasonable in the absence of left ventricle dysfunction/dilation if there is a high likelihood of a successful and durable repair and an expected mortality less than 1%
Patients with severe, chronic, secondary mitral regurgitation (stage D) who remain severely symptomatic despite optimal medical therapy
Patients with moderate or severe, chronic, secondary mitral regurgitation (stage C or D) who are undergoing other cardiac surgical procedures (eg, coronary artery bypass grafting)

Mitral valve replacement