Medical Care:
" Prehospital care
o Acute mitral valve regurgitation with hemodynamic compromise is usually associated with coronary artery disease and possible myocardial infarction. Close attention to the electrocardiogram tracings and treatment with supplemental oxygen, analgesics for anginal chest pain, and sublingual nitrates for acute myocardial infarction are the components of prehospital care.
o If exacerbation of the chronic mitral valve regurgitation with hemodynamic compromise occurs, acute myocardial infarction, although less likely, must be excluded. Treatment involves diuretics for pulmonary congestion and afterload-reducing agents, such as nitrates, to help forward cardiac output.
o According to American Heart Association recommendations, patients with few or no symptoms (eg, just recurrent chest pain, New York Heart Association class I) and echocardiogram findings that confirm mitral regurgitation but a normal ejection fraction, normal left ventricular function, and no other cardiac abnormalities should be reevaluated clinically in 6 months and should undergo a repeat echocardiogram in 12 months.
" Emergency department care
o Any patient with acute or chronic mitral valve regurgitation with hemodynamic compromise should be evaluated for acute myocardial infarction.
o Consultations with specialists in cardiology and cardiothoracic surgery should be obtained early during patient stabilization.
o Diuretic therapy is continued for individuals with pulmonary congestion, and an echocardiogram must be performed immediately. These patients must be expeditiously transferred to a cardiac critical care unit for central and pulmonary artery pressure monitoring.
" Medical therapy
o Afterload-reducing agents, such as nitrates and antihypertensive drugs, are helpful for maintaining the forward-flow state in persons with mitral valve regurgitation.
o If atrial fibrillation is encountered, digitalis therapy is considered.
o Similar to other valvular diseases, prophylactic antibiotics are administered prior to any interventional treatment. However, the current American Heart Association guidelines for endocarditis prophylaxis in patients with mitral prolapse indicate that patients with no murmur and normal leaflets are at low risk; therefore, antibiotic prophylaxis is not necessary.
o In late-stage mitral valve regurgitation, heart failure develops; diuretics and inotropic agents are administered, and consultation with a specialist in cardiothoracic surgery is arranged.
o The use of balloon counterpulsation should be considered as a preoperative measure.
Surgical Care:
" Indications for surgical intervention
o Acute mitral regurgitation (MR) with congestive heart failure or cardiogenic shock
o Acute endocarditis
o Class III/IV symptoms (ie, patient symptomatic while at rest or with minimal activity)
o Class I/II (few or no) symptoms with evidence of deteriorating LV function as evidenced by (1) an ejection fraction less than 0.55, (2) fractional shortening less than 30%, and (3) either the end-diastolic diameter approaching 75 mm or the end-systolic diameter approaching 50 mm
o Systemic emboli
o End-systolic volume index greater than 60 mL/m2 - Most commonly used parameter
" Surgical options
o Mitral valve reconstruction with mitral annuloplasty, quadratic segmental resection, shortening of the elongated chordae, or posterior leaflet resection
o Mitral valve replacement with either a mechanical valve (requiring lifelong anticoagulation) or a bioprosthetic porcine valve.
DRUG TREATMENT :
1. DIURETICS :
- FRUSEMIDE
2. ACE INHIBITORS :
- CAPTOPRIL
- ENALAPRIL
- LISINOPRIL
3. NITRATES :
- NITROGLYCERINE
4. INOTROPICS :
- DIGOXIN
5. ANTIBIOTICS : AS PROPHYLACTIC
- AMPICILLIN
- AMOXYCILLIN
- CLINDAMYCIN
- GENTAMYCIN
- VANCOMYCIN
- ERYTHROMYCIN
- AZITHROMYCIN
- CLARITHROMYCIN
- CEFAZOLIN
6. BETA BLOCKERS : TO CONTROL HEART RATE
7. ANTICOAGULANTS : IN CASE OF ATRIAL FIBRILLATION
8. AFTER LOAD THERAPY : IS INDICATED IN ACUTE REGURGITATION