Is it necessary to treat a leaking mitral valve?

Severe mitral leakage, even without symptoms, should not be ignored. A mitral valve that leaks severely will ultimately lead to damage to the heart, both the lower part (ventricle) and upper part (atrium). Longstanding severe mitral leakage leads to ballooning or dilation of the left ventricle, which ultimately starts losing its force of contraction or pump force (also called ejection fraction or EF). The normal EF of the human heart is between 60 and 65%. Persons with severe asymptomatic mitral leakage will often have ‘normal’ LV function, but many experts argue that an ejection fraction of 55-60% in the setting of severe mitral leakage is not ‘normal,’ as the left ventricle (pumping chamber of the heart) typically compensates for severe mitral leakage by working ‘harder’ or becoming hyperdynamic. Nevertheless, if severe leakage is left alone, the left ventricle will eventually dilatate and decline in its pumping power. The left atrium is the first to dilate or enlarge in the presence of severe mitral leakage and in time, this can lead to abnormal rhythm of the heart called atrial fibrillation, which is a risk factor for stroke at a 1% rate per year. All these events can alter the survival of a person with severe mitral regurgitation.

Patients with severe mitral leakage without symptoms, even with apparent normal ejection fraction should consider getting their mitral valve repaired. In fact, the current guidelines for mitral valve management from the American Heart Association and American College of Cardiology recommend patients with severe mitral regurgitation who can undergo a mitral valve repair with a low risk of death (1% or less) with a probability of successful repair of 95% or higher should be referred for surgical consideration to a valve center of excellence. If severe mitral leakage is left unattended and heart failure ensues secondary to loss of pump power of the ventricle the life expectancy of the person is diminished. In these circumstances other forms of treatment need to be considered, sometimes a percutaneous option such as the mitral clipping, or in more advanced cases, ventricular assist devices or heart pumps, even heart transplantation for those who are good candidates.

Signs of worsening valve problems…

As discussed before, persons with mitral valve leakage or stenosis may be asymptomatic early in their disease process. As the degree of leakage or tightening reaches severe symptoms start. In our experience persons in their 60’s and 70’s attribute their newly acquired fatigue or mild shortness of breath to the natural process of ‘aging’. We hear often “I thought I was just getting older”. The fact is that certain changes are not part of natural aging. For example, a drop in a persons ability to to walk the same distance on a flat surface due to shortness of breath, should be analyzed. Stopping to “catch your breath” at the end of one flight of stairs when 3 months ago that was not the case is also problem. Leg swelling with sudden weight gain likely represents fluid retention, and when associated with mitral valve disease it should be studied and corrected medically. Not being able to lay flat due to shortness of breath in someone with severe mitral leakage is a completely abnormal sign and should prompt medical care.

Cardiologist should only refer for surgical evaluation persons with severe mitral leakage by echocardiogram or those with severe mitral tightening when not amenable to percutaneous therapies. The guidelines today support treating persons with severe mitral leakage even without symptoms when the chances of a successful repair with a low complication rate are high. When having a conversation with a personal cardiologist it is important to ask which valve problem one has, its severity, its cause, and the whether it falls in the category of problems to repair or to replace.