Acute mitral regurgitation treatment

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Rim Halaby, M.D. [3]

Overview

Surgery is the main treatment of symptomatic acute severe primary mitral regurgitation (MR) and it should be performed urgently without any delay. Although some patients with moderate acute MR develop some compensatory mechanisms, surgery remains the treatment of choice for the majority of patients with acute MR. Medical therapy with vasodilators might be needed to decrease the afterload and thereby decrease the regurgitant fraction until surgery can be performed. Prior to the surgical procedure, an intra-aortic balloon pump or percutaneous circulatory assist device might also be used to stabilize the patient.[1]

Medical Therapy

The main treatment of acute mitral regurgitation is urgent surgery. Medical therapy should be provided to stabilize the patient during the diagnostic work up and before surgery. Surgery should not be delayed.

  • 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.[4]
  • Among patients with hemodynamic compromise, percutaneous circulatory assist device can also be used to stabilize the patient before surgery.[1]

Surgery

Surgery is the main treatment of symptomatic acute severe primary mitral regurgitation and it should be performed urgently without any delay. Although some patients with moderate acute MR develop some compensatory mechanisms, surgery remains the treatment of choice for the majority of patients with acute MR.

In comparison to elective surgeries, the mortality rate is higher in emergency mitral valve surgery with a mortality rate of 23% at 30 days following surgery.[5] There was no difference in mortality between mitral valve repair or mitral valve replacement.

The choice between mitral valve repair and mitral valve replacement depends upon the etiology and extent of the valvular damage.

  • Patients with rupture of the chordae tendineae should preferably undergo early mitral valve repair if possible because it associated with less operative mortality and better lon-term survival in comparison to mitral valve replacement.

In patients with acute mitral regurgitation due to endocarditis, early valve replacement surgery during hospitalization is recommended in the following conditions:[6][7]

In the absence of these conditions, elective surgery may be appropriate.

Click here to read more about surgery in mitral regurgitation.

References

  1. 1.0 1.1 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 63 (22): 2438–88. doi:10.1016/j.jacc.2014.02.537. PMID 24603192.
  2. Chatterjee K, Parmley WW, Swan HJ, Berman G, Forrester J, Marcus HS (1973). "Beneficial effects of vasodilator agents in severe mitral regurgitation due to dysfunction of subvalvar apparatus". Circulation. 48 (4): 684–90. PMID 4744778. Retrieved 2011-03-18. Unknown parameter |month= ignored (help)
  3. Harshaw CW, Grossman W, Munro AB, McLaurin LP (1975). "Reduced systemic vascular resistance as therapy for severe mitral regurgitation of valvular origin". Annals of Internal Medicine. 83 (3): 312–6. PMID 1180426. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  4. Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "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". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-03-18. Unknown parameter |month= ignored (help)
  5. Lorusso R, Gelsomino S, De Cicco G, Beghi C, Russo C, De Bonis M, Colli A, Sala A (2008). "Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study". European Journal of Cardio-thoracic Surgery : Official Journal of the European Association for Cardio-thoracic Surgery. 33 (4): 573–82. doi:10.1016/j.ejcts.2007.12.050. PMID 18313322. Retrieved 2011-03-18. Unknown parameter |month= ignored (help)
  6. "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  7. Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)


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