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 or chordae tendineae rupture, is a medical and surgical emergency. Patients may present with acute pulmonary edema or cardiogenic shock and most often definitive treatment is valvular surgery. However, medical therapy may be needed to stabilize the patient until surgery.

Medical Therapy
Normotensive patients: Vasodilators may be of use to decrease the afterload seen by the left ventricle 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 decrease the degree of mitral regurgitation.

In patients with acute mitral regurgitation secondary to myocardial ischemia/infarction, early coronary revascularization can be done through percutaneous intervention.

Surgical approach
The surgical options are mitral valve repair and mitral valve replacement depending on the etiology and extent of damage. In comparison to elective surgeries, the mortality rate is higher in emergency mitral valve surgeries with approximately 23% mortality rate in 30 days post-surgery with no bearing of different surgical approaches (repair and replacement) on mortality rate.

Chordae tendineae or papillary muscle rupture: Individuals with rupture of chordae tendineae or papillary muscle can undergo early mitral valve repair which has a better preservation of left ventricular function and long term survival rate in comparison to mitral valve replacement.

Infective endocarditis:In 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. While 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 as it depends on extent of destruction of valve.