How do you manage suspected mitral valve disease?

From the Guidelines

The primary differentiation between a rheumatic mitral valve and a non-rheumatic mitral valve lies in their etiology, pathology, and clinical presentation, with rheumatic mitral valve disease often resulting from rheumatic fever and characterized by valve fibrosis and calcification, whereas non-rheumatic mitral valve disease may result from various causes such as degenerative changes, infective endocarditis, or trauma. When managing suspected mitral valve disease, a comprehensive approach is necessary, beginning with confirmation through echocardiography and a thorough history and physical examination focusing on cardiac auscultation for murmurs and appropriate imaging 1. Key considerations include:

• The etiology of the mitral valve disease, whether rheumatic or non-rheumatic, as this influences management strategies and outcomes 1.
• For mitral regurgitation, management depends on severity, symptoms, and left ventricular function, with asymptomatic patients requiring regular monitoring and symptomatic patients or those with reduced ejection fraction referred for surgical evaluation 1.
• Medical therapy may include ACE inhibitors, beta-blockers, and diuretics for symptom management in mitral regurgitation, and anticoagulation with warfarin for patients with mitral stenosis and atrial fibrillation 1.
• Percutaneous balloon valvuloplasty or surgical intervention may be considered for symptomatic patients with mitral stenosis and valve area <1.5 cm² 1.
• Regular follow-up is essential to monitor disease progression and adjust management strategies as needed, with the goal of preventing complications like heart failure, pulmonary hypertension, and atrial fibrillation while optimizing quality of life 1. The most recent and highest quality study, published in 2023, emphasizes the importance of understanding the etiology, clinical presentation, diagnosis, and progression of mitral valve disease, as well as knowledge of appropriate management strategies, including medical therapy and percutaneous or surgical intervention 1.

From the Research

Differentiation between Rheumatic and Non-Rheumatic Mitral Valve

• The differentiation between a rheumatic mitral valve and a non-rheumatic mitral valve is crucial for determining the appropriate treatment approach 2, 3.
• Rheumatic mitral valve disease is often characterized by valve stenosis or regurgitation due to acute rheumatic fever, whereas non-rheumatic mitral valve disease can result from degenerative conditions, such as Barlow's or fibroelastic disease, or secondary to ischemic or nonischemic cardiomyopathies 4, 3.
• Echocardiography plays a vital role in assessing the etiology and severity of mitral valve disease, as well as characterizing longitudinal chamber changes to determine optimal therapies 4, 5.

Management of Suspected Mitral Valve Disease

• The management of suspected mitral valve disease involves a comprehensive evaluation, including echocardiography, stress echo, cardiac CT scanning, and cardiac MRI, to determine the underlying cause and severity of the disease 3, 5.
• For severe rheumatic mitral stenosis, medical therapy is often ineffective, and definitive therapy entails percutaneous mitral balloon commissurotomy (PMBC) in patients with suitable morphological mitral valve characteristics or surgery 3.
• In patients with rheumatic heart disease, mitral valve repair is associated with reduction in operative and long-term mortality and bleeding, but it entails a higher rate of reoperation during follow-up 2, 6.
• The choice between mitral valve repair and replacement should be based on individual patient characteristics, including the severity of the disease, left ventricular function, and the presence of comorbidities 2, 6.