Mitral valve regurgitation — or mitral regurgitation — is when your heart's mitral valve doesn't close tightly, allowing blood to flow backward in your heart. As a result, blood can't move through your heart or to the rest of your body as efficiently, making you feel tired or out of breath.

Treatment of mitral valve regurgitation — also called mitral insufficiency or mitral incompetence — depends on how severe your condition is, whether it's getting worse and whether you have symptoms. For mild cases, treatment may not be necessary.

You may need heart surgery to repair or replace the valve for severe cases. Left untreated, severe mitral valve regurgitation can cause heart failure or heart rhythm problems (arrhythmias).

Signs and symptoms of mitral valve regurgitation, which depend on its severity and how quickly the condition develops, can include:

  • Blood flowing turbulently through your heart (heart murmur)
  • Shortness of breath (dyspnea), especially with exertion or when you lie down
  • Fatigue, especially during times of increased activity
  • Cough, especially at night or when lying down
  • Heart palpitations — sensations of a rapid, fluttering heartbeat
  • Swollen feet or ankles

Mitral regurgitation is often mild and progresses slowly. You may have no symptoms for decades and be unaware that you have this condition, and it might not progress.

Your doctor might first suspect you have mitral regurgitation upon detecting a heart murmur. Sometimes, however, the problem develops quickly, and you may experience a sudden onset of severe signs and symptoms.

When to see a doctor

If you develop symptoms that suggest mitral valve regurgitation or another problem with your heart, see your doctor right away. Sometimes the first indications are actually those of mitral valve regurgitation's complications, including heart failure, a condition in which your heart can't pump enough blood to meet your body's needs.

Mitral valve regurgitation is classified as primary and secondary. Primary mitral regurgitation is caused by an abnormality in the mitral valve; secondary is caused by an abnormality in the left ventricle of the heart.

Possible causes of mitral valve regurgitation include:

  • Mitral valve prolapse. In this condition, the leaflets and tendon-like cords supporting the mitral valve weaken and stretch so that with each contraction of the left ventricle, the valve leaflets bulge (prolapse) into the left atrium. This common heart defect can prevent the mitral valve from closing tightly and lead to regurgitation.
  • Damaged tissue cords. Over time, the tissue cords that anchor the flaps of the mitral valve to the heart wall may stretch or suddenly tear, especially in people with mitral valve prolapse. A tear can cause substantial leakage through the mitral valve relatively suddenly and may require repair by heart surgery. Trauma to the chest also can rupture the cords.
  • Rheumatic fever. Rheumatic fever — a complication of untreated strep throat and once a common childhood illness in the United States — can damage the mitral valve, leading to mitral valve regurgitation later in life. Rheumatic fever is rare in the United States, but still common in developing countries.
  • Endocarditis. The mitral valve may be damaged by an infection of the lining of the heart (endocarditis) that can involve heart valves.
  • Heart attack. A heart attack can damage the area of the heart muscle that supports the mitral valve, affecting the function of the valve. If the damage is extensive enough, a heart attack can cause sudden and severe mitral valve regurgitation.
  • Abnormality of the heart muscle (cardiomyopathy). Over time, certain conditions, such as high blood pressure, can cause your heart to work harder, gradually enlarging your heart's left ventricle. This can stretch the tissue around your mitral valve, which can lead to leakage.
  • Congenital heart defects. Some babies are born with defects in their hearts, including damaged heart valves.
  • Certain drugs. Prolonged use of certain drugs, such as ergotamine, used to treat migraines and other conditions, can cause mitral valve regurgitation.

How the heart works

The heart, the center of your circulatory system, consists of four chambers. The two upper chambers, the atria, receive blood. The two lower chambers, the ventricles, pump blood.

Four heart valves open and close to let blood flow in only one direction through your heart. The mitral valve — which lies between the two chambers on the left side of your heart — comprises two flaps of tissue called leaflets.

The mitral valve opens when blood flows from the left atrium to the left ventricle. Then the flaps close to prevent the blood that has just passed into the left ventricle from flowing backward.

In mitral valve regurgitation, the mitral valve doesn't close tightly. With each heartbeat, blood from the left ventricle flows backward into the left atrium instead of moving forward into the aorta.

Several factors can increase your risk of mitral valve regurgitation, including:

  • A history of mitral valve prolapse or mitral valve stenosis. However, having either condition doesn't necessarily mean you'll develop mitral valve regurgitation. A family history of valve disease also can increase risk.
  • A heart attack. A heart attack can damage your heart, affecting the function of the mitral valve.
  • Use of certain medications. People who take ergotamine and similar medicines for migraines and those who took pergolide (now off the market) have an increased risk of mitral regurgitation. Similar problems were noted with the appetite suppressants fenfluramine and dexfenfluramine, which are no longer sold.
  • Infections such as endocarditis or rheumatic fever. Infections or the inflammation they cause can damage the mitral valve.
  • Congenital heart disease. Some people are born with an abnormal mitral valve prone to regurgitation.
  • Age. By middle age, many people have some mitral valve regurgitation caused by natural deterioration of the valve.

When it's mild, mitral valve regurgitation may not cause problems. However, severe, mitral valve regurgitation can lead to these complications:

  • Heart failure. Heart failure results when your heart can't pump enough blood to meet your body's needs. Severe mitral valve regurgitation places an extra strain on the heart because, with blood pumping backward, there is less blood going forward with each beat. The left ventricle gets bigger and, if untreated, weakens. This can cause heart failure.

    Plus, pressure builds in your lungs, leading to fluid accumulation, which strains the right side of the heart.

  • Atrial fibrillation. The stretching and enlargement of your heart's left atrium may lead to this heart rhythm irregularity in which the upper chambers of your heart beat chaotically and rapidly. Atrial fibrillation can cause blood clots, which can break loose from your heart and travel to other parts of your body, causing serious problems, such as a stroke if a clot blocks a blood vessel in your brain.
  • Pulmonary hypertension. If you have long-term untreated or improperly treated mitral regurgitation, you can develop a type of high blood pressure that affects the arteries in the lungs (pulmonary hypertension). A leaky mitral valve can increase pressure in the left atrium, which can eventually cause pulmonary hypertension, which can lead to heart failure on the right side of the heart.

If you think you have mitral valve regurgitation, make an appointment to see your doctor. Here's some information to help you prepare for your appointment.

What you can do

  • Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do beforehand.
  • Write down your symptoms, including any that seem unrelated to mitral valve regurgitation.
  • Write down key personal information, including a family history of heart disease, heart defects, genetic disorders, stroke, high blood pressure or diabetes, and any major stresses or recent life changes.
  • Make a list of all medications, vitamins and supplements you take.
  • Take a family member or friend along, if possible. Someone who accompanies you can help you remember information you receive.
  • Be prepared to discuss your diet and exercise habits. If you don't already eat well and exercise, be ready to talk to your doctor about challenges you might face in getting started.
  • Write down questions to ask your doctor.

For mitral valve regurgitation, some basic questions to ask your doctor include:

  • What is likely causing my symptoms or condition?
  • What are other possible causes for my symptoms or condition?
  • What tests will I need?
  • What's the best treatment?
  • What are the alternatives to the primary approach you're suggesting?
  • I have other health conditions. How can I best manage them together?
  • Are there restrictions I need to follow?
  • Should I see a specialist?
  • If I need surgery, which surgeon do you recommend for mitral valve repair?
  • Is there a generic alternative to the medicine you're prescribing?
  • Are there brochures or other printed material I can take with me? What websites do you recommend?

Don't hesitate to ask other questions you have.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, including:

  • When did your symptoms begin?
  • Have your symptoms been continuous or occasional?
  • How severe are your symptoms?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

Your doctor will ask about your medical history, your family history of heart disease and give you a physical exam that includes listening to your heart with a stethoscope. Mitral valve regurgitation usually produces a heart murmur, the sound of blood leaking backward through the mitral valve.

Your doctor will then decide which tests are needed to make a diagnosis. For testing, you may be referred to a cardiologist.

Diagnostic tests

Common tests to diagnose mitral valve stenosis include:

  • Echocardiogram. Sound waves directed at your heart from a wand-like device (transducer) held on your chest produce video images of your heart in motion. An echocardiogram helps your doctor get a close look at the mitral valve and how well it's working.
  • Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on your skin measure electrical impulses from your heart, providing information about your heart rhythm. You might walk on a treadmill or pedal a stationary bike during an ECG to see how your heart responds to exertion.
  • Chest X-ray. This enables your doctor to determine whether the left atrium or the left ventricle is enlarged — possible indicators of mitral valve regurgitation — and the condition of your lungs.
  • Transesophageal echocardiogram. A small transducer attached to the end of a tube is inserted down your esophagus, which allows a closer look at the mitral valve than a regular echocardiogram does.
  • Cardiac catheterization. This invasive technique involves threading a thin tube (catheter) through a blood vessel in your arm or groin to an artery in your heart and injecting dye through the catheter to make the artery visible on an X-ray. This provides a detailed picture of your heart arteries and how your heart functions. It can also measure the pressure inside the heart chambers.

Mitral valve regurgitation treatment depends on how severe your condition is, and if it's getting worse. The goal of treatment is to improve your heart's function while minimizing your signs and symptoms and avoiding future complications.

Watchful waiting

Some people, especially those with mild regurgitation, might not need treatment. However, the condition may require monitoring by your doctor. You may need regular evaluations, with the frequency depending on how severe your condition is.

Medications

Medication can't correct a mitral valve deformity. But medications such as diuretics can relieve fluid accumulation in your lungs or legs, which can accompany mitral valve regurgitation. Blood thinners (anticoagulants), which can help prevent blood clots, may be used if you have atrial fibrillation.

High blood pressure makes mitral valve regurgitation worse, so if you have high blood pressure, your doctor may prescribe medication to help lower it. Following a low-salt diet helps prevent fluid buildup and helps control blood pressure.

Surgery

Your mitral valve may need surgical repair or replacement, even if it's not causing symptoms. The American College of Cardiology and the American Heart Association recently issued new guidelines for mitral valve surgery, recommending earlier surgery for some people with primary mitral valve regurgitation — caused by an abnormality of the valve — even if they have no symptoms.

Mitral valve surgery should be done at a high-volume mitral valve surgery center with a reputation of excellence and cardiologists, imaging specialists and cardiac surgeons with experience in treating mitral valve conditions.

Discuss the risks and benefits of surgery with your doctor. Your surgery options include:

  • Valve repair. Mitral valve repair is a surgery that preserves your own valve. For most people with mitral valve damage, repair is preferred over replacement. Surgeons can repair the valve by reconnecting valve leaflets or by removing excess valve tissue so that the leaflets can close tightly.

    Frequently, repairing the valve includes tightening or replacing the ring around the valve (annulus). This is called an annuloplasty. Methods of repairing mitral valves without open-heart surgery are being used in select cases.

  • Valve replacement. Your surgeon removes the narrowed valve and replaces it with a mechanical or tissue valve. Mechanical valves, made from metal, are durable but carry the risk of blood clots forming. If you receive a mechanical mitral valve, you'll need to take an anticoagulant medication, such as warfarin (Coumadin), for life to prevent blood clots.

    Tissue valves — which may come from a pig, cow or human deceased donor — may eventually need to be replaced. Your doctor can discuss the risks and benefits of each type of heart valve with you.

Talk to your doctor about what type of follow-up you need after surgery, and let your doctor know if you develop new symptoms or if your symptoms worsen after treatment.

Less invasive techniques

Mitral valve repair or replacement generally requires open-heart surgery under general anesthesia and with the use of a heart-lung bypass machine. Less invasive surgical techniques, such as using a small, lighted tube through a small incision to see the surgical area (percutaneous approach), are being explored for mitral valve surgery.

Minimally invasive cardiac surgery is associated with less pain, a shorter hospital stay and fewer complications. However, the surgery is appropriate only in certain circumstances. Talk to your surgeon to see if this type of surgery might be right for you.

To improve your quality of life, your doctor may recommend that you:

  • Check your blood pressure regularly. Control of high blood pressure is important if you have mitral valve regurgitation.
  • Eat a heart-healthy diet. Food doesn't directly affect mitral valve regurgitation. But a healthy diet can help prevent other heart disease that can weaken the heart muscle. Eat foods that are low in saturated and trans fats, sugar, salt, and refined grains, such as white bread. Eat a variety of vegetables and fruits, whole grains, and proteins, such as lean meats, fish and nuts.
  • Maintain a healthy weight. Keep your weight within a range recommended by your doctor.
  • Cut back on caffeine. Caffeine can worsen irregular heartbeats (arrhythmias). Ask your doctor about drinking beverages with caffeine, such as coffee or soft drinks.
  • Cut back on alcohol. Heavy alcohol use can cause arrhythmias and can make your symptoms worse. Excessive alcohol use can also cause cardiomyopathy, a condition of weakened heart muscle that leads to mitral regurgitation. Ask your doctor about the effects of drinking alcohol.
  • Exercise. How long and hard you're able to exercise depends on the severity of your condition and the intensity of exercise. Ask your doctor for guidance before starting to exercise, especially if you're considering competitive sports.
  • See your doctor regularly. Establish a regular evaluation schedule with your cardiologist or primary care provider.

If you're a woman with mitral valve regurgitation, discuss family planning with your doctor before you become pregnant. Pregnancy causes the heart to work harder. How a heart with mitral valve regurgitation tolerates this extra work depends on the degree of regurgitation and how well your heart pumps. Throughout your pregnancy and after delivery, your cardiologist and obstetrician should monitor you.

For any heart condition, see your doctor regularly so he or she can monitor you and possibly catch mitral valve regurgitation in its early stages, when it's more easily treatable. Also, be aware of conditions that contribute to developing mitral valve regurgitation, including:

  • Rheumatic fever. If you have a severe sore throat, see a doctor. Untreated strep throat can lead to rheumatic fever. Fortunately, strep throat is easily treated with antibiotics.
  • High blood pressure. Check your blood pressure regularly. Make sure it's well-controlled because high blood pressure contributes to heart disease.
  • Mitral valve prolapse. If you have this or another condition that affects your heart valves, see your doctor regularly. Seek urgent medical care if you develop a fever or symptoms of an infection of your heart lining (endocarditis).
  • Heart attack. To reduce your risk of heart attack, don't smoke, exercise regularly, manage your blood pressure and cholesterol, and eat a heart-healthy diet.
Aug. 28, 2014