Moderate Mitral Valve Regurgitation

[Tinu1959]

Can mitral valve regurgitation be reversed. As per echo(at rest) report I had mild MR at the time of MI nine months back. Yesterday I got the stress echo test and the report says moderate mitral valve regurgitation. LA is dilated(it is for quite some time) and LA is dilated since MI. The report reads as "moderate 2/4 MR at rest and moderate MR at impost" and "restrictive flow pattern at rest and at impost". I am really upset about this development. I am concerned that I am heading towards irreversible development of disease.My EF is 30% at rest and 35% at impost.

With increase in my beta blockers and ACE-I I have been able to bring my pulse rate from 75-90 to 65-75 since last week. My BP is around 110/70.

Is it possible to improve MR(reduce it)?? How?? Or may be retaining it at "moderate" level.

Thanks in advance.

[Tinu1959]

Thanks for responding and answering my quarries.

[kenkeith]

MVR can be reversed depending on the underlying cause. Ischemic dilated cardiomyopathy (LVE  and sometimes LAE secondary to LVE)  to changes in ventricular shape and failure of mitral leaflet coaptation. Medical treatment should be directed to the underlying cardiomyopathy with the use of an ACE inhibitor, a beta blocker, digoxin, and a diuretic. ACE inhibitors and beta blockers have also been shown to reduce the degree of mitral regurgitation.
Surgical repair of severe mitral regurgitation may be considered for patients with dilated cardiomyopathy who have symptomatic (I am asymptomatic) heart failure despite medical therapy, although a survival benefit to this approach has not been demonstrated.

Globally, annular dilatation occurs secondary to left ventricular (LV) enlargment, causing incomplete coaptation of the mitral valve despite normal leaflet motion. Locally, inferior wall remodelling produces papillary muscle displacement with restricted motion of the mitral leaflets.

Chronic ischemic mitral regurgitation (IMR) is a common complication of myocardial infarction. Multiple pathophysiologic mechanisms, such as left ventricular (LV) remodeling and dysfunction, annular dilation/dysfunction, and mechanical dyssynchrony, are involved in generating IMR. initially creating regurgitation is the presence of local or global LV remodeling that alters the geometrical relationship between the ventricle and valve apparatus.

Medical and/or surgical therapy is to ameliorate heart failure symptoms, and improve LV remodeling and function and the intermediate/long-term outcome. The targets of surgical MV repair involve annulus, leaflets, chordae and ventricles. The mitral valve annuloplasty with the annulus (ring) restores leaflet coaptation and eliminates mitral regurgitation by effectively modifying the mitral annular geometry.

MVR was reduced from severe to moderate and no symptoms. For me, MVR surgery  is not recommeded when there are no symptoms relieved with mediation. Three years ago my Stress test was stopped at 4 minutes 30 seconds (7.2 METs) with a mm ST segment depression.  Currently, with medication,  I can do 7 MET with no time limits and that is considered good enough to avoid intervention.

Yes, I had hypokinesos at the distal portion of the heart.  A later echo showed no impairment and a normal EF and heart size.

If you job is stressful or physically challenging, your doctor may advise lighter duties.  I didn't have that problem as I was retired.

[Tinu1959]

Thankyou for sharing the experience.

Kenkeith, can you please also share with me whether your MVR was reversed or MVR remained static at one level. What I understand from your mail is that if the underlying cause of LV and LA dilation, which can be ischemia, can be mitigated by drugs(beta blockers, ACE-I and nitrates) they may reduce in size leading to MVR reduction??? Is this what your experience is??

In your case the LV walls resumed their movement over a period of time and EF also increased which must have reduced the load on LV. In my case some of the wall sections of LV are akinitic and others are hypokinitic. With EF of 30% do you see possibility of LA and LV size reversal and MVR reduction??  Will reduction in my activities(take a long leave from job) help?? At this stage I have no symptoms and physically I am experiencing gradual(very slow) improvement.

I did 7.9 MET(6.4 minutes) at stress test with minor deviation in resting EKG(QS pattern in I, aVL, II, III, aVF, mild ST changes) post stress and 79% of my maximum predicted heart rate. My BP at that time was 140/80.

Please respond as your feedback is important to me. Thanks.

[Momto3]

Kenkeith is right.  I have non-ischemic MR, probably caused by MVP.  Sorry, I probably should have clarified that.  Good catch : )

[kenkeith]

I believe Momto3 and Smiley2000 are referring to primary MRV.  Your post information suggests ischemic MVR secondary to an MI.  My condition is similar.

For some perspictive a normal mitral valve function is dependent not only on the integrity of the underlying valvular structure, but on that of the adjacent myocardium as well.  Mitral regurgitation imposes an extra load on the heart because the left ventricle pumps more blood per beat in order to maintain its normal output. Not a favorable circumstance when in the process of recovering from an MI (slows the recovery and works against reducing the heart's workload).  

Ischemic MVR: "Chronic mitral regurgitation frequently is the result of scarring of the papillary muscles due to ischemia or infarction, but more often is the result of infarction of the left ventricular wall where the papillary muscle is attached. Chronic ischemic mitral regurgitation usually is treated medically, but surgery is indicated when it is severe or when it is necessary to treat underlying coronary artery disease surgically; in these situations, mitral valve repair is preferred over replacement. Medical treatment is based on achieving afterload reduction with an ACE inhibitor or other vasodilator in order to REDUCE LV SIZE AND THEREBY REDUCE LV SIZE AND THEREBY PRODUCE A CONCOMITANT REDUCTION IN BOTH MITRAL ANNULAR SIZE AND THE DEGREE OF MITRAL VALVE REGURGITATION.  In addition, anti-ischemic agents such as nitrates and beta blockers are used in situations when mitral regurgitation is worsened by acute ischemia

I'm not sure how an enlarged LA is involved.  Usually, an enlarged LA is the result of abnorml pressures caused by MV stenosis.  Involvement is usually the left ventricle that has impaired LV wall movement from an MI and the LV is dilated.

Smiley, good to hear you have had a successful valve operation :)

[Momto3]

Hi tinu1959 and Smiley2000!

Yep, I've known about my MR for at least 25 years.  The last report stated "moderate" but a lot of the interpretation is subeject to variation since machines, technicians, etc. can change.  In my case, I've been going to the same facility for about 10 years and it helps because the doctor has all of the studies.  My reports have stated everything from "mild" to "moderately severe".  A TEE came back with a reading of 2  3+, so again, there is variation.  What's important is the doctor correlate the findings to your body type, symptoms, history and physical.  

I just had an echo done and the doctor said the LV was at the high end of normal, but everything overall looked the same, so no changes of note.

Keep in mind the radiologists are reading the studies and the measurements are so small that there is room for variance.  Unless you are symptomatic and/or your regurg. is severe, just be sure to follow up and keep your doctor aware of any new or changing symptoms.  If you notice changes that could be attributed (SOB, increasing arrythmias, unusual fatigue, etc), be sure to let your doctor know.

Smiley2000,
Sounds like you are doing well!!  I'll be the kids are glad "your're back!"

[Smiley2000]

Hi there.  I am 6 1/2 weeks post-op after OHS to repair mitral valve.  I had mild MV regurg for 1 year and then from Sept. 2007 - March 2008 it developed into severe MV regurg and dilated left Atrium.  I was very symptomatic for the 6 months pre-op:  SOB with exertion, CHF, irregular heartbeat, muscle weakness, palpitations.

The post-op report said that I had a birth defect:  3 bad segments and 2 holes in annulus.  Up and until the op the Cardio and Surgeon had no idea what caused my MV problems.

Some people on this forum (like Momto3) have had mild to moderate MV regurg for years and as long as they are not symptomatic, the Cardio will just monitor it.

Having said that:  I think your LA dilation is directly related to your MV regurg and I were you I would ask my Cardio to at least do a TEE.

MV regurg will either stay at "moderate" level or become severe, in which case it is time for Surgery.  But the only person that can determine the "timing" for surgery, is a Thoracic Surgeon.