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Therapeutic decision-making for patients with fluctuating mitral regurgitation

Nature Reviews Cardiology volume 12, pages 212–219 (2015)Cite this article

Subjects

Key Points

  • Mitral regurgitation (MR) often varies dynamically with changes in loading conditions

  • Dynamic fluctuation of MR can precipitate symptoms and induce left ventricular remodelling, and might have prognostic value

  • An intermittent increase in MR is often accompanied by dynamic pulmonary hypertension

  • The optimal treatment strategy for fluctuating MR is uncertain, but can include a combination of surgery, cardiac resynchronization therapy, and new mitral valve approaches

Abstract

Mitral regurgitation (MR) is a common, progressive, and difficult-to-manage disease. MR is dynamic in nature, with physiological fluctuations occurring in response to various stimuli such as exercise and ischaemia, which can precipitate the development of symptoms and subsequent cardiac events. In both chronic primary and secondary MR, the dynamic behaviour of MR can be reliably examined during stress echocardiography. Dynamic fluctuation of MR can also have prognostic value; patients with a marked increase in regurgitant volume or who exhibit increased systolic pulmonary artery pressure during exercise have lower symptom-free survival than those who do not experience significant changes in MR and systolic pulmonary artery pressure during exercise. Identifying patients who have dynamic MR, and understanding the mechanisms underlying the condition, can potentially influence revascularization strategies (such as the surgical restoration of coronary blood flow) and interventional treatment (including cardiac resynchronization therapy and new approaches targeted to the mitral valve).

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Figure 1: Transthoracic Doppler echocardiogram of a patient with symptomatic ischaemic cardiomyopathy, severe left ventricular dysfunction, and moderate secondary mitral regurgitation at rest.
Figure 2: Transthoracic Doppler echocardiogram showing a substantial decrease in secondary mitral regurgitation severity observed after dobutamine administration.
Figure 3: Transoesophageal Doppler echocardiogram in a patient with a clinical history of flash pulmonary oedmea and fluctuating mitral regurgitation.
Figure 4: Management of patients with moderate secondary MR and left ventricular dysfunction.

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Authors and Affiliations

  1. Department of Cardiology, GIGA Cardiovascular Sciences, Heart Valve Clinic, University Hospital Sart Tilman, University of Liège, Place du 20 Août 7, Liège, 4000, Belgium

    Patrizio Lancellotti

  2. Cardiac Surgery Unit, GVM Care and Research, Maria Eleonora Hospital, Viale della Regione Siciliana Nord Ovest 1571, Palermo, Italy

    Khalil Fattouch

  3. Cardiac Surgery Department, Echocardiography Unit, San Raffaele Scientific Institute, Via Olgettina 58, Milan, 20132, Italy

    Giovanni La Canna

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All the authors researched data for the article, discussed its content, and wrote, reviewed, and edited the manuscript before submission.

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Correspondence to Patrizio Lancellotti.

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Lancellotti, P., Fattouch, K. & La Canna, G. Therapeutic decision-making for patients with fluctuating mitral regurgitation. Nat Rev Cardiol 12, 212–219 (2015). https://doi.org/10.1038/nrcardio.2015.16

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