Acute mitral regurgitation treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Acute mitral regurgitation secondary to left ventricular papillary muscle rupture or chordae tendineae rupture, is a medical and surgical emergency. Patients may present with acute pulmonary edema or cardiogenic shock and most often the required and definitive treatment is valvular surgery. However, medical therapy may be needed to stabilize the patient until surgery can be performed.
Medical Therapy
Treatment of acute severe mitral regurgitation depends on the stability of the patient.
Normotensive patients
- Vasodilators may be of use to decrease the afterload and thereby decrease the regurgitant fraction. The vasodilator most commonly used is nitroprusside [1][2]. ACE inhibitors may be useful as oral therapy.
- Antibiotics
- Diuretics
- Anti-ischemic agents
- Operate in endocarditis if progressive CHF, no response to antibiotics, abscessor recurrent embolism.
Hypotensive patients
- Intravenous nitroprusside with ionotropes if needed to support blood pressure.
- If medical therapy is not effective, an intra aortic balloon pump can be inserted to maintain hemodynamic stability.
- Prior to the surgical procedure, an intra-aortic balloon pump may be placed in order to improve perfusion of the organs and to reduce afterload and thereby decrease the degree of mitral regurgitation [3].
- Surgical treatment is usually indicated.
- Knowledge of the etiology of the mitral regurgitation is important to know if the valve can be repaired or replaced.
- In patients with acute mitral regurgitation secondary to myocardial ischemia/infarction, early coronary revascularization should be performed.
Surgical approach
Mitral Valve Repair Versus Mitral Valve Replacement
The choice between mitral valve repair and mitral valve replacement depends upon the etiology and extent of the valvular damage.
Chordae tendineae or papillary muscle rupture
- Patients with rupture of the chordae tendineae or papillary muscle should undergo early mitral valve repair if possible which results in a better preservation of left ventricular function, reduces the risk of endocarditis and improves long term survival in comparison to mitral valve replacement [4].
Infective endocarditis
- In patients with 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 [5]. 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 if there is extensive destruction of the valve apparatus.
Prognosis
In comparison to elective surgeries, the mortality rate is higher in emergency mitral valve surgery with a mortality rate of 23% at 30 days folowing surgery.[6]. There was no difference in mortality between mitral valve repair or mitral valve replacement.
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) - ↑ 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) - ↑ 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)