Symptoms, Treatment & Procedures

Mitral Valve Regurgitation

Mitral Valve Regurgitation

In a normally functioning mitral valve, blood flows in a single direction from the left atrium to the left ventricle. In Mitral Regurgitation, the leaflets do not close properly resulting in some blood flowing backwards through the valve into the left atrium. Leakage occurs through the mitral valve each time the left ventricle contracts. Mitral regurgitation can occur due to degenerative mitral regurgitation (ie damaged leaflets) or functional mitral regurgitation (ie leaflets not coapting properly). Mitral regurgitation puts a strain on the heart. For people who cannot undergo surgery, Transcatheter Mitral Valve Repair (TMVR) offers a minimally invasive treatment for correcting most forms of mitral valve leakage and improving the patient’s quality of life. If left untreated, Mitral Regurgitation may lead to congestive heart failure and eventually, death.

Anatomy of the Mitral Valve

There is a new treatment for patients who have a leaky Mitral Valve. The treatment you need depends on how severe the leak is and how unwell you are. Let’s look at the anatomy of the Mitral Valve.

The Mitral Valve is a saddle-shaped valve with two tapered cusps. It sits between the left atrium and the left ventricle and is made up of two flaps of tissue, called leaflets. The leaflets are surrounded by a ring called the annulus. Filaments of connective tissue, called chordae (CORE-day), connect the underside of the valve to papillary muscles, small muscles inside the left ventricle. The chordae and papillary muscles anchor the mitral valve and help it open and close

 

Types of Mitral Valve Regurgitation

  • Degenerative Mitral Regurgitation is also known as primary or organic Mitral Regurgitation. It is caused by an abnormality in the mitral valve itself. Degenerative MR can be related to age, a valve abnormality present from birth, heart disease, coronary artery disease, or rheumatic fever history.
  • Functional Mitral regurgitation occurs when the left atrium or left ventricle dilates, causing the mitral valve annulus to dilate, thus preventing the mitral valve leaflets from coapting properly.

Symptoms of Mitral Valve Regurgitation:

  • Shortness of breath
  • Heart palpitations —rapid or fluttering heartbeat
  • Swollen feet or ankles
  • Fatigue
  • Coughing
  • Lightheadedness
  • Peripheral oedema
  • Increased micturition

Phases of Mitral Valve Regurgitation

Compensated phase 

  • Mild mitral regurgitation may not have any symptoms
  • Heart rhythm is usually normal
  • The leak is not severe
  • Surgical treatment is generally not required
Symptoms of Mitral Regurgitation

Transitional phase 

  • Changes in heart structure
  • Changes in the hearts pumping function
  • Other changes may occur as progressively greater volumes of blood are leaking backward
  • The heart muscle (myocardium) begins to weaken
  • The ventricle can no longer compensate for the regurgitation
  • When regurgitation is more severe, a person may have palpitations, often due to atrial fibrillation
  • Red Flags: Patients may experience fatigue, with a decreased ability to exercise or be active, or they may feel short of breath. However, some people may have no symptoms.
  • It is recommended that Surgical or TMVR treatment is considered when the patient enters the transitional phase.

Decompensated phase 

  • In severe MR the left ventricle has enlarged to maintain a forward flow of blood. As a result, the left ventricle functions less efficiently
  • Abnormal heart rhythms are identified on an echocardiography
  • The blood pressure in the pulmonary arteries (the blood vessels from the heart to the lungs) increases (pulmonary hypertension).
  • Red Flags: Heart failure is advancing, the further it develops the more it becomes irreversible.

My Approach to Mitral Valve Treatment

I have experience in successfully implanting the MitraClip®. Norwest Private Hospital commenced this procedure in 2020.  I recommend any patient with the above symptoms to undergo an echocardiogram and if evidence of significant mitral regurgitation to be referred to a Heart Team for evaluation of the best approach to management.

A/Prof Peter Fahmy leads the heart team at Norwest Private Hospital and is able to review these patients.

Treatment options

Treatment for mitral regurgitation depends on how severe it is and how unwell the patient is. There are medications available to reduce symptoms, but no medications address the mitral valve’s underlying problem.

Mitral Regurgitation itself can be treated in two ways: 

Mitral valve surgery – There are two types of surgery to treat mitral regurgitation:

  • Mitral valve repair: Repair of the natural valve is preferred over replacement. If the valve cannot be repaired, it is replaced with an artificial valve
  • Mitral Valve Replacement: This is when the mitral valve cannot be repaired and instead a new valve is placed surgically.

Transcatheter mitral valve repair – Transcatheter Mitral Valve Repair (TMVR) is a minimally invasive procedure that may be an option for patients who are at high risk for surgery. Unlike surgery, this procedure does not require opening the chest and temporarily stopping the heart. In this procedure, a clip will be implanted onto the centre of the mitral valve. This reduces mitral regurgitation, and the valve continues to open and close on either side of the clip, allowing blood to flow through.

While open-heart surgery is an effective treatment for mitral regurgitation, alternative treatment due to your age, advanced heart failure, or other severe medical conditions can be considered. Most patients can leave the hospital within 2 to 5 days after surgery.

Other Cardiology Treatment & Procedures

Arrhythmias

Heart arrhythmia is a heart relates services that refers to a group of symptoms where the heartbeat is irregular, too slow, or too fast. Arrhythmias are broken down into:

  • Slow heartbeat (bradycardia).
  • Fast heartbeat (tachycardia).
  • Irregular heartbeat (flutter or fibrillation).
  • Early heartbeat (premature contraction).
ASD and PFO closures Patent Foramen Ovale (PFO)

The heart is divided into four chambers. The upper chambers are called the right and left atria. The lower chambers are the right and left ventricles. In fetal circulation, the foramen ovale is an opening that allows blood to bypass the lungs and go directly from the right atria to the left atria. Shortly after birth, the higher pressure in the left atria and the lower pressure in the right atria causes permanent closure of the foramen ovale in the majority of people. A PFO occurs when the opening does not close. This opening can allow blood to pass from the right atria to the left atria. Many times a PFO is not discovered until adulthood.

PFO’s are suspected to be a cause of cryptogenic stroke (a stroke that cannot be linked to a specific cause). Some research suggests there may be a link between PFO’s and migraine headaches.

Atrial septal defect (ASD)

An ASD is a hole in the part of the septum that separates the atria—the upper chambers of the heart. This heart defect allows oxygen-rich blood from the left atrium to flow into the right atrium instead of flowing to the left ventricle as it should. Many children who have ASDs have few if any, symptoms.

Heart Failure

Heart failure occurs when the heart muscle has become too weak or too stiff to pump blood through the body as effectively as normal.

Intravascular Ultrasound

Intravascular Ultrasound (or IVUS) lets cardiologists see inside a coronary artery in real time, yielding information beyond routine imaging methods such as coronary angiography or non-invasive Multislice CT scans.

Ischemic Heart disease

Ischemic heart disease occurs when damage or disease in the heart's major blood vessels arise, and it reduces the blood supply to the heart.

Left Atrial Appendage Closure (LAAC)

The Left Atrial Appendage is a small sac in the muscle wall of the left atrium. The Left Atrial Appendage Closure (LAAC) uses a device that ofers some patients who experience atrial fibrillation an alternative to long-term anticoagulation (warfarin or NOAC) therapy through a minimally invasive procedure.

Percutaneous Coronary Intervention (PCI)

Percutaneous Coronary Intervention (PCI) is sometimes called angioplasty with a stent. PCI is a non-surgical procedure that uses a catheter to place a stent in the heart's blood vessel that has been narrowed by plaque build-up. Adjunctive imaging is sometimes used to further assist in a coronary intervention such as Intravascular Ultrasound  (IVUS) and Intravascular Optical Coherence Tomography (OCT).

This diagnostic imaging allows Interventional Cardiologists such as Dr Fahmy to see inside a coronary artery in real-time. The sound waves help to explore the blood vessels and assess various conditions. These tests are beyond routine imaging methods available with your GP, such as Coronary Angiography or non-invasive Multislice CT scans. The IVUS and OCT test provide heart specialists with detailed information to diagnose and treat. 

Intravascular optical coherence tomography (OCT) can add value to angiography as a diagnostic and/or intervention tool for percutaneous coronary intervention (PCI) guidance.

Rotablation

This is a procedure which attempts to “bore out” a narrowing in a coronary artery which might not otherwise respond to stenting.

Structural Heart Disease (SHD)

Structural Heart Disease is a heart relates services for people with structural heart disease that falls into two categories:

  1. People are born with the disease – i.e. a hole within the chambers of the heart
  2. They acquired Structural Heart Disease through wear and tear – i.e. a tight or leaky heart valve.
Tranascatheter Aortic Valve Implantation (TAVI)
Transcatheter Aortic Valve Implantation is a cardiac procedure where a new aortic valve is implanted using a long narrow tube called a catheter. Usually, the catheter is inserted into a large blood vessel in your groin or through a small incision in your chest.