Acute mitral regurgitation treatment: Difference between revisions
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Acute mitral regurgitation secondary to left ventricular papillary muscle or chordae tendineae rupture, is a medical and surgical emergency. Patients may present with acute pulmonary edema or cardiogenic shock and most often definitive treatment is valvular surgery. However, medical therapy may be needed to stabilize the patient until surgery. | |||
==Medical Therapy== | |||
'''Normotensive patients:''' [[Vasodilators]] may be of use to decrease the [[afterload]] seen by the left ventricle and thereby decrease the regurgitant fraction. The [[vasodilator]] most commonly used is [[nitroprusside]]<ref name="pmid4744778">{{cite journal |author=Chatterjee K, Parmley WW, Swan HJ, Berman G, Forrester J, Marcus HS |title=Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus |journal=[[Circulation]] |volume=48 |issue=4 |pages=684–90 |year=1973 |month=October |pmid=4744778 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=4744778 |accessdate=2011-03-18}}</ref><ref name="pmid1180426">{{cite journal |author=Harshaw CW, Grossman W, Munro AB, McLaurin LP |title=Reduced systemic vascular resistance as therapy for severe mitral regurgitation of valvular origin |journal=[[Annals of Internal Medicine]] |volume=83 |issue=3 |pages=312–6 |year=1975 |month=September |pmid=1180426 |doi= |url= |accessdate=2011-03-18}}</ref>. [[ACE inhibitors]] may be useful as oral therapy. | |||
'''[[Hypotensive]] patients:''' Prior to the surgical procedure, an [[intra-aortic balloon pump]] may be placed in order to improve perfusion of the organs and to decrease the degree of mitral regurgitation<ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=[[Circulation]] |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=18820172 |accessdate=2011-03-18}}</ref>. | |||
In patients with acute mitral regurgitation secondary to '''[[myocardial ischemia]]/[[infarction]]''', early coronary revascularization can be done through [[percutaneous intervention]] | |||
==Surgical approach== | |||
The surgical options are [[mitral valve repair]] and [[mitral valve replacement]] depending on the etiology and extent of damage. | |||
In comparison to elective surgeries, the mortality rate is higher in emergency mitral valve surgeries with approximately 23% mortality rate in 30 days post-surgery with no bearing of different surgical approaches(repair and replacement) on mortality rate.<ref name="pmid18313322">{{cite journal |author=Lorusso R, Gelsomino S, De Cicco G, Beghi C, Russo C, De Bonis M, Colli A, Sala A |title=Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study |journal=[[European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery]] |volume=33 |issue=4 |pages=573–82 |year=2008 |month=April |pmid=18313322 |doi=10.1016/j.ejcts.2007.12.050 |url=http://linkinghub.elsevier.com/retrieve/pii/S1010-7940(08)00061-4 |accessdate=2011-03-18}}</ref> | In comparison to elective surgeries, the mortality rate is higher in emergency mitral valve surgeries with approximately 23% mortality rate in 30 days post-surgery with no bearing of different surgical approaches(repair and replacement) on mortality rate.<ref name="pmid18313322">{{cite journal |author=Lorusso R, Gelsomino S, De Cicco G, Beghi C, Russo C, De Bonis M, Colli A, Sala A |title=Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study |journal=[[European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery]] |volume=33 |issue=4 |pages=573–82 |year=2008 |month=April |pmid=18313322 |doi=10.1016/j.ejcts.2007.12.050 |url=http://linkinghub.elsevier.com/retrieve/pii/S1010-7940(08)00061-4 |accessdate=2011-03-18}}</ref> | ||
'''[[Chordae tendineae]] or [[papillary muscle rupture]]:'''Individuals with rupture of chordae tendineae or papillary muscle can undergo early [[mitral valve repair]] which has a better preservation of left ventricular function and long term survival rate in comparison to [[mitral valve replacement]]. <ref>Society of Thoracic Surgeons National Cardiac Surgery Database. Available at : http://www.sts.org/documents/pdf/STSExecutiveSummaryFall2005.pdf. Accessed November 2005</ref> | |||
'''[[Infective endocarditis]]:'''In acute mitral regurgitation due to [[endocarditis]], urgent surgery is recommended in the setting of persistent [[cardiac failure]], [[pulmonary hypertension]], [[Staphylococcus aureus]] infection, paravalvular abscess, and systemic embolism<ref name="pmid20159831">{{cite journal |author=Lalani T, Cabell CH, Benjamin DK, Lasca O, Naber C, Fowler VG, Corey GR, Chu VH, Fenely M, Pachirat O, Tan RS, Watkin R, Ionac A, Moreno A, Mestres CA, Casabé J, Chipigina N, Eisen DP, Spelman D, Delahaye F, Peterson G, Olaison L, Wang A |title=Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias |journal=[[Circulation]] |volume=121 |issue=8 |pages=1005–13 |year=2010 |month=March |pmid=20159831 |doi=10.1161/CIRCULATIONAHA.109.864488 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=20159831 |accessdate=2011-03-18}}</ref>. While in absence of cardiac failure, elective surgery may be appropriate. [[Mitral valve repair]] is preferred over valve replacement due to benefits mentioned above. However it might not always be possible to perform valve repair in endocarditis as it depends on extent of destruction of valve. | |||
==References== | ==References== | ||
Revision as of 21:26, 18 March 2011
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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Acute mitral regurgitation secondary to left ventricular papillary muscle or chordae tendineae rupture, is a medical and surgical emergency. Patients may present with acute pulmonary edema or cardiogenic shock and most often definitive treatment is valvular surgery. However, medical therapy may be needed to stabilize the patient until surgery.
Medical Therapy
Normotensive patients: Vasodilators may be of use to decrease the afterload seen by the left ventricle and thereby decrease the regurgitant fraction. The vasodilator most commonly used is nitroprusside[1][2]. ACE inhibitors may be useful as oral therapy.
Hypotensive patients: Prior to the surgical procedure, an intra-aortic balloon pump may be placed in order to improve perfusion of the organs and to decrease the degree of mitral regurgitation[3].
In patients with acute mitral regurgitation secondary to myocardial ischemia/infarction, early coronary revascularization can be done through percutaneous intervention
Surgical approach
The surgical options are mitral valve repair and mitral valve replacement depending on the etiology and extent of damage. In comparison to elective surgeries, the mortality rate is higher in emergency mitral valve surgeries with approximately 23% mortality rate in 30 days post-surgery with no bearing of different surgical approaches(repair and replacement) on mortality rate.[4]
Chordae tendineae or papillary muscle rupture:Individuals with rupture of chordae tendineae or papillary muscle can undergo early mitral valve repair which has a better preservation of left ventricular function and long term survival rate in comparison to mitral valve replacement. [5]
Infective endocarditis:In acute mitral regurgitation due to endocarditis, urgent surgery is recommended in the setting of persistent cardiac failure, pulmonary hypertension, Staphylococcus aureus infection, paravalvular abscess, and systemic embolism[6]. While in absence of cardiac failure, elective surgery may be appropriate. Mitral valve repair is preferred over valve replacement due to benefits mentioned above. However it might not always be possible to perform valve repair in endocarditis as it depends on extent of destruction of valve.
References
- ↑ Chatterjee K, Parmley WW, Swan HJ, Berman G, Forrester J, Marcus HS (1973). "Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus". Circulation. 48 (4): 684–90. PMID 4744778. Retrieved 2011-03-18. Unknown parameter
|month=ignored (help) - ↑ Harshaw CW, Grossman W, Munro AB, McLaurin LP (1975). "Reduced systemic vascular resistance as therapy for severe mitral regurgitation of valvular origin". Annals of Internal Medicine. 83 (3): 312–6. PMID 1180426. Unknown parameter
|month=ignored (help);|access-date=requires|url=(help) - ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-03-18. Unknown parameter
|month=ignored (help) - ↑ Lorusso R, Gelsomino S, De Cicco G, Beghi C, Russo C, De Bonis M, Colli A, Sala A (2008). "Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study". European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery. 33 (4): 573–82. doi:10.1016/j.ejcts.2007.12.050. PMID 18313322. Retrieved 2011-03-18. Unknown parameter
|month=ignored (help) - ↑ Society of Thoracic Surgeons National Cardiac Surgery Database. Available at : http://www.sts.org/documents/pdf/STSExecutiveSummaryFall2005.pdf. Accessed November 2005
- ↑ Lalani T, Cabell CH, Benjamin DK, Lasca O, Naber C, Fowler VG, Corey GR, Chu VH, Fenely M, Pachirat O, Tan RS, Watkin R, Ionac A, Moreno A, Mestres CA, Casabé J, Chipigina N, Eisen DP, Spelman D, Delahaye F, Peterson G, Olaison L, Wang A (2010). "Analysis of the impact of early surgery on in-hospital mortality of native valve endocarditis: use of propensity score and instrumental variable methods to adjust for treatment-selection bias". Circulation. 121 (8): 1005–13. doi:10.1161/CIRCULATIONAHA.109.864488. PMID 20159831. Retrieved 2011-03-18. Unknown parameter
|month=ignored (help)