Acute mitral regurgitation treatment


 * Associate Editor-In-Chief: ; 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.

Normotensive patients
Vasodilators may be of use to decrease the afterload and thereby decrease the regurgitant fraction. The vasodilator most commonly used is nitroprusside. 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 reduce afterload and thereby decrease the degree of mitral regurgitation.

In patients with acute mitral regurgitation secondary to myocardial ischemia/infarction, early coronary revascularization should be performed.

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.

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 . 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. . There was no difference in mortality between mitral valve repair or mitral valve replacement.