Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Treatment and management of mitral regurgitation

Nature Reviews Cardiology volume 9, pages 133–146 (2012)Cite this article

Abstract

Mitral regurgitation (MR) is the most-common valvular heart disease in the western world. From an etiologic point of view, MR can be either organic (mainly degenerative in western countries) or functional (secondary to left ventricular remodeling in the context of ischemic or idiopathic dilated cardiomyopathy). Degenerative and functional MR are completely different disease entities that pose specific decision-making problems and require different management. The natural history of severe degenerative MR is clearly unfavorable. However, the appropriate and timely correction of degenerative MR is associated with a life expectancy similar to that of the normal population. By contrast, the prognostic impact of the correction of functional MR is still a matter of debate. In this Review, we discuss the optimal treatment of both degenerative and functional MR, taking into account all presently available therapeutic options, including novel percutaneous methods. Since a clear understanding of the etiology and mechanisms of valvular dysfunction is important to guide the timing and choice of treatment, the role of echocardiography in the management of MR is also addressed.

Key Points

  • Degenerative and functional mitral regurgitation (MR) are completely different disease entities, each posing specific challenges with regard to decision-making and management

  • 2D and 3D echocardiography capture important physiological information and provide the roadmap for the treatment of patients with MR

  • Surgical mitral valve (MV) repair is the preferred treatment for patients with severe degenerative MR and can improve life expectancy to normal levels if performed adequately and in a timely manner

  • In patients with functional MR, annuloplasty should only be carried out in the presence of echocardiographic predictors of successful repair; MV replacement should be considered when unsatisfactory results are expected

  • Transcatheter correction of MR (MV repair or replacement) represents a novel field of cardiovascular medicine and is expected to change surgical practice in the future

  • Use of the MitraClip® should currently be reserved for patients with functional or degenerative MR who are unsuitable for surgery or have a very high surgical risk

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Real-time 3D transesophageal echocardiography images of a degenerative myxomatous mitral valve.
Figure 2: Myxomatous mitral valve with bileaflet prolapse and severe valve regurgitation.
Figure 3: Mitral valve with fibroelastic deficiency.
Figure 4: Barlow disease with calcific degeneration (arrow) involving the posterior leaflet.
Figure 5: Echocardiographic parameters in functional mitral regurgitation.
Figure 6: MitraClip® (Evalve, Menlo Park, CA, USA) implantation.

Similar content being viewed by others

References

  1. Nkomo, V. T. et al. Burden of valvular heart diseases: a population-based study. Lancet 368, 1005–1011 (2006).

    Article  PubMed  Google Scholar 

  2. Iung, B. & Vahanian A. Epidemiology of valvular heart disease in the adult. Nat. Rev. Cardiol. 8, 162–172 (2011).

    PubMed  Google Scholar 

  3. Bursi, F. et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 111, 295–301 (2005).

    PubMed  Google Scholar 

  4. Grigioni, F., Enriquez-Sarano, M., Zehr, K. J., Bailey, K. R. & Tajik, A. J. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 103, 1759–1764 (2001).

    CAS  PubMed  Google Scholar 

  5. Ling, L. H. et al. Clinical outcome of mitral regurgitation due to flail leaflet. N. Engl. J. Med. 335, 1417–1423 (1996).

    CAS  PubMed  Google Scholar 

  6. Detaint, D. et al. Surgical correction of mitral regurgitation in the elderly: outcomes and recent improvements. Circulation 114, 265–272 (2006).

    PubMed  Google Scholar 

  7. Bonow, R. O. et al. 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. J. Am. Coll. Cardiol. 52, e1–e142 (2008).

    PubMed  Google Scholar 

  8. Vahanian, A. et al. Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur. Heart J. 28, 230–268 (2007).

    PubMed  Google Scholar 

  9. Iung, B. et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur. Heart J. 24, 1231–1243 (2003).

    Article  PubMed  Google Scholar 

  10. Monin, J. L. et al. Functional assessment of mitral regurgitation by transthoracic echocardiography using standardized imaging planes. J. Am. Coll. Cardiol. 46, 302–309 (2005).

    PubMed  Google Scholar 

  11. Foster, G. P. et al. Accurate localization of mitral regurgitant defects using multiplane transesophageal echocardiography. Ann. Thorac. Surg. 65, 1025–1031 (1998).

    CAS  PubMed  Google Scholar 

  12. Grewal, J. et al. Real-time three-dimensional transesophageal echocardiography assessment of mitral valve disease. J. Am. Soc. Echocardiography 22, 34–41 (2009).

    Google Scholar 

  13. La Canna, G. et al. Real-time three-dimensional transesophageal echocardiography for assessment of mitral valve functional anatomy in patients with prolapse-related regurgitation. Am. J. Cardiol. 107, 1365–1374 (2011).

    PubMed  Google Scholar 

  14. Levine, R. A. et al. Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse. Circulation 80, 589–598 (1989).

    CAS  PubMed  Google Scholar 

  15. Carpentier, A. Cardiac valve surgery—the “French correction”. J. Thorac. Cardiovasc. Surg. 86, 323–337 (1983).

    CAS  PubMed  Google Scholar 

  16. Kumar, N., Kumar, M. & Duran C. M. A revised terminology for recording surgical findings of the mitral valve. J. Heart Valve Dis. 4, 70–75 (1995).

    CAS  PubMed  Google Scholar 

  17. Flameng, W., Meuris, B., Herijgers, P. & Herregods, M. C. Durability of mitral repair in Barlow disease versus fibroelastic deficiency. J. Thorac. Cardiovasc. Surg. 135, 274–282 (2008).

    PubMed  Google Scholar 

  18. Enriquez-Sarano, M. et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N. Engl. J. Med. 352, 875–883 (2005).

    CAS  PubMed  Google Scholar 

  19. Barbieri, A. et al. Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: a multicenter long-term international study. Eur. Heart J. 32, 751–759 (2011).

    PubMed  Google Scholar 

  20. Messika-Zeitoun, D. et al. Left atrial remodelling in mitral regurgitation—methodologic approach, physiological determinants, and outcome implications: a prospective quantitative Doppler-echocardiographic and electron beam-computed tomographic study. Eur. Heart J. 28, 1773–1781 (2007).

    PubMed  Google Scholar 

  21. Tribouilloy, C. et al. Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets. J. Am. Coll. Cardiol. 54, 1961–1968 (2009).

    PubMed  Google Scholar 

  22. Pizarro, R. et al. Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J. Am. Coll. Cardiol. 54, 1099–1106 (2009).

    CAS  PubMed  Google Scholar 

  23. Messika Zeitoun, D. et al. Cardiopulmonary exercise testing determination of functional capacity in mitral regurgitation: physiologic and outcome implications. J. Am. Coll. Cardiol. 47, 2521–2527 (2006).

    PubMed  Google Scholar 

  24. Lancellotti, P. et al. Importance of left ventricular longitudinal function and functional reserve in patients with degenerative mitral regurgitation: assessment by 2-D speckle tracking. J. Am. Soc. Echocardiogr. 21, 1331–1336 (2008).

    PubMed  Google Scholar 

  25. Magne, J., Lancellotti, P. & Piérard, L. A. Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. Circulation 122, 33–41 (2010).

    PubMed  Google Scholar 

  26. Magne, J., Lancellotti, P. & Piérard, L. A. Exercise-induced changes in degenerative mitral regurgitation. J. Am. Coll. Cardiol. 56, 310–313 (2010).

    Google Scholar 

  27. Montant, P. et al. Long-term survival in asymptomatic patients with severe degenerative mitral regurgitation: a propensity score-based comparison between an early surgical strategy and a conservative treatment approach. J. Thorac. Cardiovasc. Surg. 138, 1339–1348 (2009).

    PubMed  Google Scholar 

  28. Rosenhek, R. et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 113, 2238–2244 (2006).

    PubMed  Google Scholar 

  29. Le Tourneau, T. et al. Impact of left atrial volume on clinical outcome in organic mitral regurgitation. J. Am. Coll. Cardiol. 56, 570–578 (2010).

    PubMed  Google Scholar 

  30. Grigioni, F. et al. Outcomes in mitral regurgitation to flail leaflets: a multicenter European study. JACC Cardiovasc. Imaging 1, 133–141 (2008).

    PubMed  Google Scholar 

  31. Gillinov, A. M. et al. Valve repair versus valve replacement for degenerative mitral valve disease. J. Thorac. Cardiovasc. Surg. 135, 885–893 (2008).

    PubMed  Google Scholar 

  32. Adams, D. H. et al. Large annuloplasty rings facilitate mitral valve repair in Barlow's disease. Ann. Thorac. Surg. 82, 2096–2100 (2006).

    PubMed  Google Scholar 

  33. Gammie, J. S., Bartlett, S. T. & Griffith, B. P. Small-incision mitral valve repair: safe, durable, and approaching perfection. Ann. Surg. 250, 409–415 (2009).

    PubMed  Google Scholar 

  34. Holzhey, D. M. et al. Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison. Ann. Thorac. Surg. 91, 401–405 (2011).

    PubMed  Google Scholar 

  35. Casselman, F. P. et al. Endoscopic mitral valve repair: feasible, reproducible, and durable. J. Thorac. Cardiovasc. Surg. 125, 273–282 (2003).

    PubMed  Google Scholar 

  36. Chitwood, W. R. et al. Robotic mitral valve repairs in 300 patients: a single-center experience. J. Thorac. Cardiovasc. Surg. 136, 436–441 (2008).

    PubMed  Google Scholar 

  37. Gammie, J. S., Bartlett, S. T. & Griffith, B. P. Small-incision mitral valve repair: safe, durable, and approaching perfection. Ann. Surg. 250, 409–415 (2009).

    PubMed  Google Scholar 

  38. Flameng, W., Herijjers, P. & Bogaerts, K. Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease. Circulation 107, 1609–1613 (2003).

    PubMed  Google Scholar 

  39. David, T. E. Artificial chordae. Semin. Thorac. Cardiovasc. Surg. 16, 161–168 (2004).

    PubMed  Google Scholar 

  40. Alfieri, O. et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J. Thorac. Cardiovasc. Surg. 122, 674–681 (2001).

    CAS  PubMed  Google Scholar 

  41. Braunberger, E. et al. Very long-term results (more than 20 years) of valve repair with Carpentier's techniques in nonrheumatic mitral valve insufficiency. Circulation 104 (Suppl. 1), I8–I11 (2001).

    CAS  PubMed  Google Scholar 

  42. Crescenzi, G. et al. Management and decision-making strategy for systolic anterior motion after mitral valve repair. J. Thorac. Cardiovasc. Surg. 137, 320–325 (2009).

    PubMed  Google Scholar 

  43. Saunders, P. C. et al. Anterior leaflet resection of the mitral valve. Semin. Thorac. Cardiovasc. Surg. 16, 188–193 (2004).

    PubMed  Google Scholar 

  44. Gillinov, A. M. & Cosgrove, D. M. Chordal transfer for repair of anterior leaflet prolapse. Semin. Thorac. Cardiovasc. Surg. 16, 169–173 (2004).

    PubMed  Google Scholar 

  45. Dreyfus, G. D., Souza Neto, O. & Aubert, S. Papillary muscle repositioning for repair of anterior leaflet prolapse caused by chordal elongation. J. Thorac. Cardiovasc. Surg. 132, 578–584 (2006).

    PubMed  Google Scholar 

  46. von Oppell, U. O. & Mohr, F. W. Chordal replacement for both minimally invasive and conventional mitral valve surgery using premeasured Gore-Tex loops. Ann. Thorac. Surg. 70, 2166–2168 (2000).

    CAS  PubMed  Google Scholar 

  47. Zussa, C. Different applications of ePTFE valve chordae: surgical technique. J. Heart Valve Dis. 5, 356–361 (1996).

    CAS  PubMed  Google Scholar 

  48. David, T. E., Armstrong, S. & Sun, Z. Replacement of chordae tendineae with Gore-Tex sutures: a ten-year experience. J. Heart Valve Dis. 5, 352–355 (1996).

    CAS  PubMed  Google Scholar 

  49. Chan, D. T., Chiu C. S., Cheng, L. C. & Au, T. W. Artificial chordae: a simple clip and tie technique. J. Thorac. Cardiovasc. Surg. 136, 1597–1599 (2008).

    PubMed  Google Scholar 

  50. Salvador, L. et al. A 20-year experience with mitral valve repair with artificial chordae in 608 patients. J. Thorac. Cardiovasc. Surg. 135, 1280–1287 (2008).

    PubMed  Google Scholar 

  51. Fucci, C. et al. Improved results with mitral valve repair using new surgical techniques. Eur. J. Cardiothorac. Surg. 9, 621–626 (1995).

    CAS  PubMed  Google Scholar 

  52. Kuduvalli, M. et al. Edge-to-edge technique for mitral valve repair: medium-term results with echocardiographic follow-up. Ann. Thorac. Surg. 82, 1356–1361 (2006).

    PubMed  Google Scholar 

  53. Brinster, D. R. et al. Midterm results of the edge-to-edge technique for complex mitral valve repair. Ann. Thorac. Surg. 81, 1612–1617 (2006).

    PubMed  Google Scholar 

  54. Bhudia, S. K. et al. Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings. Ann. Thorac. Surg. 77, 1598–1606 (2004).

    PubMed  Google Scholar 

  55. Kherani, A. R. et al. Edge-to-edge mitral valve repair: the Columbia Presbyterian experience. Ann. Thorac. Surg. 78, 73–76 (2004).

    PubMed  Google Scholar 

  56. De Bonis, M. et al. Similar long-term results of mitral valve repair for anterior compared with posterior leaflet prolapse. J. Thorac. Cardiovasc. Surg. 131, 364–368 (2006).

    PubMed  Google Scholar 

  57. Gillinov, A. M., Shortt, K. G. & Cosgrove D. M. 3rd. Commissural closure for repair of mitral commissural prolapse. Ann. Thorac. Surg. 80, 1135–1136 (2005).

    PubMed  Google Scholar 

  58. Lapenna, E. et al. Commissural closure for the treatment of commissural mitral valve prolapse or flail. J. Heart Valve Dis. 17, 261–266 (2008).

    PubMed  Google Scholar 

  59. Maisano, F. et al. The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique. Eur. J. Cardiothorac. Surg. 17, 201–205 (2000).

    CAS  PubMed  Google Scholar 

  60. Dreyfus, G., Corbi, P. J., Chan, K. M. & Bahrami, T. Secondary tricuspid regurgitation or dilatation: which should be the criteria for surgical repair? Ann. Thorac. Surg. 79, 127–132 (2005).

    PubMed  Google Scholar 

  61. Schaff, H. V., Dearani, J. A., Daly, R. C, Orszulak, T. A. & Danielson, G. K. Cox–maze procedure for atrial fibrillation: Mayo Clinic experience. Semin. Thorac. Cardiovasc. Surg. 12, 30–37 (2000).

    CAS  PubMed  Google Scholar 

  62. Raanani, E., Albage, A., David, T. E., Yau, T. M. & Armstrong S. The efficacy of the Cox/maze procedure combined with mitral valve surgery: a matched control study. Eur. J. Cardiothorac. Surg. 19, 438–442 (2001).

    CAS  PubMed  Google Scholar 

  63. Cox, J. L. Intraoperative options for treating atrial fibrillation associated with mitral valve disease. J. Thorac. Cardiovasc. Surg. 122, 212–215 (2001).

    CAS  PubMed  Google Scholar 

  64. Yun, K. L. & Miller, D. C. Mitral valve repair versus replacement. Cardiol. Clin. 9, 315–327 (1991).

    CAS  PubMed  Google Scholar 

  65. Olson, L. J. et al. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin. Proc. 62, 22–34 (1987).

    CAS  PubMed  Google Scholar 

  66. Gammie, J. S. et al. Influence of hospital procedural volume on care process and mortality for patients undergoing elective surgery for mitral regurgitation. Circulation 115, 881–887 (2007).

    PubMed  Google Scholar 

  67. Gillinov, A. M. et al. Should patients with severe degenerative mitral regurgitation delay surgery until symptoms develop? Ann. Thorac. Surg. 90, 481–488 (2010).

    PubMed  Google Scholar 

  68. Savage, E. B., Ferguson, T. B. Jr &. DiSesa, V. J. Use of mitral valve repair: analysis of contemporary United States experience reported to the Society of Thoracic Surgeons National Cardiac Database. Ann. Thorac. Surg. 75, 820–825 (2003).

    PubMed  Google Scholar 

  69. David, T. E., Ivanov, J, Armstrong, S., Christie, D. & Rakowski H. A comparison of outcomes of mitral valve repair for degenerative disease with posterior, anterior, and bileaflet prolapse. J. Thorac. Cardiovasc. Surg. 130, 1242–1249 (2005).

    PubMed  Google Scholar 

  70. Russo, A. et al. Thromboembolic complications after surgical correction of mitral regurgitation incidence, predictors, and clinical implications. J. Am. Coll. Cardiol. 51, 1203–1211 (2008).

    PubMed  Google Scholar 

  71. Markar, S. R., Sadat, U., Edmonds, L. & Nair S. K. Mitral valve repair versus replacement in the elderly population. J. Heart Valve Dis. 20, 265–271 (2011).

    PubMed  Google Scholar 

  72. Nloga, J. et al. Mitral valve surgery in octogenarians: should we fight for repair? A survival and quality-of-life assessment. Eur. J. Cardiothorac. Surg. 39, 875–880 (2011).

    PubMed  Google Scholar 

  73. Enriquez-Sarano, M. et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation 90, 830–837 (1994).

    CAS  PubMed  Google Scholar 

  74. Heikkinen, J. et al. Quality of life after mitral valve repair. J. Heart Valve Dis. 14, 722–726 (2005).

    PubMed  Google Scholar 

  75. Gillinov, A. M. et al. Durability of mitral valve repair for degenerative disease. J. Thorac. Cardiovasc. Surg. 111, 734–743 (1998).

    Google Scholar 

  76. Suri, R. M. et al. Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era. Ann. Thorac. Surg. 82, 819–826 (2006).

    PubMed  Google Scholar 

  77. Bolling, S. F. et al. Predictors of mitral valve repair: clinical and surgeon factors. Ann. Thorac. Surg. 90, 1904–1911 (2010).

    PubMed  Google Scholar 

  78. Hueb, A. C. et al. Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study. J. Thorac. Cardiovasc. Surg. 124, 1216–1224 (2002).

    PubMed  Google Scholar 

  79. Flynn, M. et al. Regional wall motion abnormalities and scarring in severe functional ischemic mitral regurgitation: a pilot cardiovascular magnetic resonance imaging study. J. Thorac. Cardiovasc. Surg. 137, 1063–1070 (2009).

    PubMed  Google Scholar 

  80. Lancellotti, P., Gérard, P. & Piérard, L. Long term outcome of patients with heart failure and dynamic mitral regurgitation. Eur. Heart J. 26, 1528–1532 (2005).

    PubMed  Google Scholar 

  81. Bolling, S. F. et al. Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy. J. Thorac. Cardiovasc. Surg. 109, 676–682 (1995).

    CAS  PubMed  Google Scholar 

  82. Bolling, S. F. et al. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J. Thorac. Cardiovasc. Surg. 115, 381–386 (1998).

    CAS  PubMed  Google Scholar 

  83. Bach, D. & Bolling, S. Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy. Am. Heart J. 129, 1165–1170 (1995).

    CAS  PubMed  Google Scholar 

  84. Silberman, S. et al. Repair of ischemic mitral regurgitation: comparison between flexible and rigid annuloplasty rings. Ann. Thorac. Surg. 87, 1721–1726 (2009).

    PubMed  Google Scholar 

  85. Spoor, M. T., Geltz, A. & Bolling, S. F. Flexible versus nonflexible mitral valve rings for congestive heart failure: differential durability of repair. Circulation 114 (Suppl. 1), I67–I71 (2006).

    PubMed  Google Scholar 

  86. Bax, J. J. et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation 110 (Suppl. 1), II103–II108 (2004).

    PubMed  Google Scholar 

  87. Braun, J. et al. Restrictive mitral annuloplasty cures ischemic mitral regurgitation and heart failure. Ann. Thorac. Surg. 85, 430–436 (2008).

    PubMed  Google Scholar 

  88. Wu, A. H. et al. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J. Am. Coll. Cardiol. 45, 381–387 (2005).

    PubMed  Google Scholar 

  89. McGee, E. C. et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J. Thorac. Cardiovasc. Surg. 128, 916–924 (2004).

    PubMed  Google Scholar 

  90. Hung, J. et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 110 (Suppl. 1), II85–II90 (2004).

    PubMed  Google Scholar 

  91. Magne, J. et al. Preoperative posterior leaflet angle accurately predicts outcome after restrictive mitral valve annuloplasty for ischemic mitral regurgitation. Circulation 115, 782–791 (2007).

    PubMed  Google Scholar 

  92. Lee, A. P. et al. Mechanisms of recurrent functional mitral regurgitation after mitral valve repair in nonischemic dilated cardiomyopathy: importance of distal anterior leaflet tethering. Circulation 119, 2606–2614 (2009).

    PubMed  Google Scholar 

  93. Braun, J. et al. Preoperative left ventricular dimensions predict reverse remodelling following restrictive mitral annuloplasty in ischaemic mitral regurgitation. Eur. J. Cardiothorac. Surg. 27, 847–853 (2005).

    PubMed  Google Scholar 

  94. Roshanali, F., Mandegar, M. H., Yousefnia, M. A., Rayatzadeh, H. & Alaeddini, F. A prospective study of predicting factors in ischemic mitral regurgitation recurrence after ring annuloplasty. Ann. Thor. Surg. 84, 745–749 (2007).

    Google Scholar 

  95. Ciarka, A. et al. Predictors of mitral regurgitation recurrence in patients with heart failure undergoing mitral valve annuloplasty. Am. J. Cardiol. 106, 395–401 (2010).

    PubMed  Google Scholar 

  96. Borger, M. A. et al. Initial results of the chordal-cutting operation for ischemic mitral regurgitation. J. Thorac. Cardiovasc. Surg. 133, 1483–1492 (2007).

    PubMed  Google Scholar 

  97. Hvass, U., Tapia, M., Baron, F., Pouzet, B. & Shafy, A. Papillary muscle sling: a new functional approach to mitral repair in patients with ischemic left ventricular dysfunction and functional mitral regurgitation. Ann. Thorac. Surg. 75, 809–811 (2003).

    PubMed  Google Scholar 

  98. Kron, I. L., Green, G. R. & Cope, J. T. Surgical relocation of the posterior papillary muscle in chronic ischemic mitral regurgitation. Ann. Thorac. Surg. 74, 600–601 (2002).

    PubMed  Google Scholar 

  99. Menicanti, L. et al. Ischemic mitral regurgitation: intraventricular papillary muscle imbrication without mitral ring during left ventricular restoration. J. Thorac. Cardiovasc. Surg. 123, 1041–1050 (2002).

    CAS  PubMed  Google Scholar 

  100. De Bonis, M. et al. Mitral valve repair for functional mitral regurgitation in end-stage dilated cardiomyopathy: role of the “edge-to-edge” technique. Circulation 112 (Suppl. 9), I402–I408 (2005).

    PubMed  Google Scholar 

  101. Mann, D. L. et al. Clinical evaluation of the CorCap Cardiac Support Device in patients with dilated cardiomyopathy. Ann. Thorac. Surg. 84, 1226–1235 (2007).

    PubMed  Google Scholar 

  102. Tulner, S. A. et al. Clinical efficacy of surgical heart failure therapy by ventricular restoration and restrictive mitral annuloplasty. J. Card. Fail. 13, 178–183 (2007).

    PubMed  Google Scholar 

  103. Vassileva, C. M., Boley, T., Markwell, S. & Hazelrigg, S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation. Eur. J. Cardiothorac. Surg. 39, 295–303 (2011).

    PubMed  Google Scholar 

  104. Gillinov, A. M. et al. Is repair preferable to replacement for ischemic mitral regurgitation? J. Thorac. Cardiovasc. Surg. 122, 1125–1141 (2001).

    CAS  PubMed  Google Scholar 

  105. De Bonis, M. & Alfieri, O. Mitral regurgitation should be corrected in patients with dilated cardiomyopathy. Nat. Clin. Pract. Cardiovasc. Med. 5, 452–453 (2008).

    PubMed  Google Scholar 

  106. Bach, D. S., Awais, M., Gurm, H. S. & Kohnstamm, S. Failure of guideline adherence for intervention in patients with severe mitral regurgitation. J. Am. Coll. Cardiol. 54, 860–865 (2009).

    PubMed  Google Scholar 

  107. Mirabel, M. et al. What are the characteristics of patients with severe, symptomatic, mitral regurgitation who are denied surgery? Eur. Heart J. 28, 1358–1365 (2007).

    PubMed  Google Scholar 

  108. Seiffert, M. et al. Series of transcatheter valve-in-valve implantations in high-risk patients with degenerated bioprostheses in aortic and mitral position. Catheter. Cardiovasc. Interv. 76, 608–615 (2010).

    PubMed  Google Scholar 

  109. Nuñez-Gil, I. J. et al. Transapical mitral valve-in-valve implantation: a novel approach guided by three-dimensional transoesophageal echocardiography. Eur. J. Echocardiogr. 12, 335–337 (2011).

    PubMed  Google Scholar 

  110. Cheung, A. W. et al. Transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis: a case series. J. Thorac. Cardiovasc. Surg. 141, 711–715 (2011).

    PubMed  Google Scholar 

  111. de Weger, A., Ewe, S. H., Delgado, V. & Bax, J. J. First-in-man implantation of a trans-catheter aortic valve in a mitral annuloplasty ring: novel treatment modality for failed mitral valve repair. Eur. J. Cardiothorac. Surg. 39, 1054–1056 (2011).

    PubMed  Google Scholar 

  112. Kawata, M., Vasilyev, N. V., Perrin, D. P. & del Nido, P. J. Beating-heart mitral valve suture annuloplasty under real-time three-dimensional echocardiography guidance: an ex vivo study. Interact. Cardiovasc. Thorac. Surg. 11, 6–9 (2010).

    PubMed  Google Scholar 

  113. Swaans, M. J., Post, M. C. & ten Berg, J. M. Transapical repair of mitral valve paravalvular leakage using 3-D transesophageal guidance. Catheter. Cardiovasc. Interv. 77, 121–123 (2011).

    PubMed  Google Scholar 

  114. Forleo, G. B. et al. Real-time integration of intracardiac echocardiography and 3D electroanatomical mapping to guide catheter ablation of isthmus-dependent atrial flutter in a patient with complete situs inversus and interruption of the inferior vena cava with azygos continuation. J. Interv. Card. Electrophysiol. 30, 273–277 (2011).

    PubMed  Google Scholar 

  115. Maisano, F. et al. Beating-heart implantation of adjustable length mitral valve chordae: acute and chronic experience in an animal model. Eur. J. Cardiothorac. Surg. 40, 840–847 (2011).

    PubMed  Google Scholar 

  116. Condado, J. A. et al. Percutaneous edge-to-edge mitral valve repair: 2-year follow-up in the first human case. Catheter. Cardiovasc. Interv. 67, 323–325 (2006).

    PubMed  Google Scholar 

  117. Feldman, T. et al. Percutaneous repair or surgery for mitral regurgitation. N. Engl. J. Med. 364, 1395–1406 (2011).

    CAS  PubMed  Google Scholar 

  118. Franzen, O. et al. Acute outcomes of MitraClip therapy for mitral regurgitation in high-surgical-risk patients: emphasis on adverse valve morphology and severe left ventricular dysfunction. Eur. Heart J. 31, 1373–1381 (2010).

    PubMed  Google Scholar 

  119. Maisano, F. European percutaneous mitral valve therapy experience: acute results in the first 1,000 patients. Data from the European ACCESS Registry: what patients have been treated in Europe? Presented at TCT 2010.

  120. Tamburino, C. et al. Percutaneous mitral valve repair with the MitraClip system: acute results from a real world setting. Eur. Heart J. 31, 1382–1389 (2010).

    CAS  PubMed  PubMed Central  Google Scholar 

  121. Maisano, F. et al. Surgical isolated edge-to-edge mitral valve repair without annuloplasty: clinical proof of the principle for an endovascular approach. EuroIntervention 2, 181–186 (2006).

    PubMed  Google Scholar 

  122. Schofer, J. et al. Percutaneous mitral annuloplasty for functional mitral regurgitation results of the CARILLON Mitral Annuloplasty Device European Union Study. Circulation 120, 326–333 (2009).

    PubMed  PubMed Central  Google Scholar 

  123. Webb, J. G. et al. Percutaneous transvenous mitral annuloplasty: initial human experience with device implantation in the coronary sinus. Circulation 113, 851–855 (2006).

    PubMed  Google Scholar 

  124. Sack, S. et al. Percutaneous transvenous mitral annuloplasty: initial human experience with a novel coronary sinus implant device. Circ. Cardiovasc. Interv. 2, 277–284 (2009).

    PubMed  Google Scholar 

  125. Lansac, E. et al. Percutaneous mitral annuloplasty through the coronary sinus: an anatomic point of view. J. Thorac. Cardiovasc. Surg. 135, 376–381 (2008).

    PubMed  Google Scholar 

  126. Webb, J. G. et al. Percutaneous suture edge-to-edge repair of the mitral valve. EuroIntervention 5, 86–89 (2009).

    PubMed  Google Scholar 

  127. Bajona, P., Katz, W. E., Daly, R. C., Zehr, K. J. & Speziali, G. Beating-heart, off-pump mitral valve repair by implantation of artificial chordae tendineae: an acute in vivo animal study. J. Thorac. Cardiovasc. Surg. 137, 188–193 (2009).

    PubMed  Google Scholar 

  128. Panic, G. et al. A novel technique for treatment of mitral valve prolapse/flail. J. Thorac. Cardiovasc. Surg. 137, 1568–1570 (2009).

    PubMed  Google Scholar 

  129. Williams, J. L. et al. Feasibility of myxomatous mitral valve repair using direct leaflet and chordal radiofrequency ablation. J. Interv. Cardiol. 21, 547–554 (2008).

    PubMed  Google Scholar 

  130. Kim, J. H. et al. Mitral cerclage annuloplasty, a novel transcatheter treatment for secondary mitral valve regurgitation: initial results in swine. J. Am. Coll. Cardiol. 54, 638–651 (2009).

    PubMed  PubMed Central  Google Scholar 

  131. Raman, J., Hare, D., Storer, M. & Hata M. Epicardial cardiac basal annuloplasty: preliminary findings on extra-cardiac mitral valve repair. Heart Lung Circ. 18, 401–406 (2009).

    PubMed  Google Scholar 

  132. Rahman, S., Eid, N., Murarka, S. & Heuser R. R. Remodeling of the mitral valve using radiofrequency energy: review of a new treatment modality for mitral regurgitation. Cardiovasc. Revasc. Med. 11, 249–259 (2010).

    PubMed  Google Scholar 

  133. Heuser, R. R., Witzel, T., Dickens, D. & Takeda, P. A. Percutaneous treatment for mitral regurgitation: the QuantumCor system. J. Interv. Cardiol. 21, 178–182 (2008).

    PubMed  Google Scholar 

  134. Jilaihawi, H. et al. Mitral annular reduction with subablative therapeutic ultrasound: pre-clinical evaluation of the ReCor device. EuroIntervention 6, 54–62 (2010).

    PubMed  Google Scholar 

  135. Lozonschi, L. et al. Transapical mitral valved stent implantation: A survival series in swine. J. Thorac. Cardiovasc. Surg. 140, 422.e1–426.e1 (2010).

    Google Scholar 

  136. Lutter, G. et al. Mitral valved stent implantation. Eur. J. Cardiothorac. Surg. 38, 350–355 (2010).

    PubMed  Google Scholar 

  137. Grossi, E. A. et al. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J. Thorac. Cardiovasc. Surg. 122, 1107–1124 (2001).

    CAS  PubMed  Google Scholar 

  138. Braun, J. et al. Preoperative left ventricular dimensions predict reverse remodelling following restrictive mitral annuloplasty in ischaemic mitral regurgitation. Eur. J. Cardiothorac. Surg. 27, 847–853 (2005).

    PubMed  Google Scholar 

  139. Magne, J. et al. Preoperative posterior leaflet angle accurately predicts outcome after restrictive mitral valve annuloplasty for ischemic mitral regurgitation. Circulation 115, 782–791 (2007).

    PubMed  Google Scholar 

  140. Lee, A. P. et al. Mechanisms of recurrent functional mitral regurgitation after mitral valve repair in nonischemic dilated cardiomyopathy: importance of distal anterior leaflet tethering. Circulation 119, 2606–2614 (2009).

    PubMed  Google Scholar 

  141. Gelsomino, S. et al. Left ventricular reverse remodeling after undersized mitral ring annuloplasty in patients with ischemic regurgitation. Ann. Thorac. Surg. 85, 1319–1330 (2008).

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiac Surgery, San Raffaele University Hospital, Via Olgettina 60, Milan, 20132, Italy

    Michele De Bonis, Francesco Maisano, Giovanni La Canna & Ottavio Alfieri

Authors
  1. Michele De Bonis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Francesco Maisano
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giovanni La Canna
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ottavio Alfieri
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed equally to researching data for the article, made substantial contributions to the discussion of content, wrote, and reviewed and edited the manuscript before submission.

Corresponding author

Correspondence to Michele De Bonis.

Ethics declarations

Competing interests

F. Maisano is, or has been, a consultant and has received honoraria from Abbott, Medtronic, St. Jude Medical, and Valtech Cardio. Additionally, he is a stockholder/director of Valtech Cardio and holds, or has applied for, patents related to the company. G. La Canna has received honoraria from Abbott. O. Alfieri is, or has been, a consultant for Symetis and is a stockholder/director of 4Tech, Edwards Lifesciences, and Valtech Cardio. M. De Bonis declares no competing interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

De Bonis, M., Maisano, F., Canna, G. et al. Treatment and management of mitral regurgitation. Nat Rev Cardiol 9, 133–146 (2012). https://doi.org/10.1038/nrcardio.2011.169

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrcardio.2011.169

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing