What are the medical causes and management of regurgitation?

Medical Causes and Management of Regurgitation

Regurgitation has multiple etiologies including valvular heart disease, gastroesophageal reflux, and mechanical causes, with treatment directed at the underlying cause and severity of symptoms. Understanding the specific type of regurgitation is critical for appropriate management.

Valvular Heart Regurgitation

Mitral Regurgitation

Causes:

• Primary (structural valve abnormalities):

  • Mitral valve prolapse
  • Leaflet degeneration or tear
  • Papillary muscle rupture (post-MI)
  • Rheumatic heart disease
  • Infective endocarditis

• Secondary (functional):

  • Left ventricular dilatation and dysfunction
  • Papillary muscle dysfunction (usually from inferior MI)
  • Mitral annular dilatation 1

Diagnosis:

• Echocardiography is the primary diagnostic tool
• Transesophageal echocardiography (TEE) is often needed for prosthetic mitral valves
• 3D TEE allows optimal visualization of defects 1

Management:

• Severe symptomatic MR: Surgical intervention is recommended
• Acute severe MR (papillary muscle rupture): Urgent surgery due to sudden hemodynamic deterioration 1
• Chronic MR:
  • Asymptomatic with preserved LV function: Regular monitoring
  • Symptomatic or with LV dysfunction: Surgical repair or replacement 1

Aortic Regurgitation

Causes:

• Aortic root dilation
• Leaflet abnormalities
• Rheumatic heart disease
• Infective endocarditis
• Congenital abnormalities
• Connective tissue disorders (Marfan syndrome)

Management:

• Symptomatic severe AR: Surgical aortic valve replacement (SAVR) regardless of LV function (Class I recommendation) 2
• Asymptomatic severe AR: Surgery indicated when:
  • LVEF ≤50-55%
  • Significant LV dilatation (LVESD >50 mm or LVEDD >70 mm)
  • Progressive LV deterioration 2
• Medical therapy:
  • Limited role and should not delay surgical intervention
  • ACE inhibitors or dihydropyridine calcium channel blockers for symptomatic improvement when surgery not feasible
  • Treatment of hypertension recommended 2, 3

Tricuspid Regurgitation

Causes:

• Primary: Flail leaflet, endocarditis, congenital abnormalities
• Secondary (functional): Most common form 4, 5
  • Pulmonary hypertension
  • Right ventricular dilatation
  • Atrial fibrillation leading to right atrial and annular dilatation

Management:

• Surgical repair during left-sided cardiac surgery if significant TR
• Isolated TR surgery has higher risk
• Emerging transcatheter options for high-risk patients 6, 4

Pulmonary Regurgitation

Causes:

• Congenital (rare as isolated defect)
• Post-surgical or balloon valvuloplasty for pulmonary stenosis
• Post-repair of tetralogy of Fallot
• Idiopathic dilation of pulmonary artery 1

Management:

• Mild PR may be normal finding on echocardiography
• Severe PR with RV dilatation and dysfunction may require pulmonary valve replacement
• Regular monitoring with cardiac MRI to assess RV volumes and function 1

Prosthetic Valve Regurgitation

Types:

• Transvalvular (through the valve)
• Paravalvular (around the valve)

Diagnosis:

• TEE is essential, especially for mitral prostheses
• 3D TEE allows optimal visualization of defects 1

Management:

• Intractable hemolysis or heart failure: Surgery recommended unless high surgical risk
• Asymptomatic severe regurgitation: Surgery reasonable with low operative risk
• High surgical risk patients: Percutaneous repair of paravalvular leak or transcatheter valve-in-valve procedure at specialized centers 1

Gastroesophageal Regurgitation

Characteristics:

• Bitter taste in mouth or sensation of fluid moving up from stomach
• Affects approximately 80% of GERD patients with varying severity 7

Management:

• Less responsive to PPIs than heartburn:
  • Therapeutic gain of PPIs above placebo only 17% for regurgitation vs. 41% for heartburn
  • Doubling PPI dose doesn't significantly decrease gastric juice volume
• For refractory regurgitation:
  • Antireflux procedures (magnetic sphincter augmentation, transoral fundoplication) successful in >85% of patients
  • Increased PPI dosing helps only ~15% of patients 7

Special Considerations

Pregnancy

• Regurgitant valve lesions generally well-tolerated during pregnancy due to:
  • Decreased systemic vascular resistance reducing regurgitant fraction
  • Tachycardia shortening diastole (beneficial in AR)
• Management during pregnancy:
  • Close monitoring, especially in third trimester
  • Diuretics if heart failure develops
  • Avoid ACE inhibitors and angiotensin receptor antagonists
  • Nitrates and dihydropyridine calcium channel blockers can be used if needed 1

Acute Myocardial Infarction

• Mitral regurgitation can occur 2-7 days post-MI
• Papillary muscle rupture presents as sudden hemodynamic deterioration
• Requires urgent surgical intervention 1

Key Management Principles

1. Accurate diagnosis of type and severity of regurgitation
2. Regular monitoring for asymptomatic patients with significant regurgitation
3. Timely intervention before irreversible ventricular dysfunction occurs
4. Surgical repair preferred over replacement when feasible
5. Consider transcatheter options for high-risk surgical patients
6. Treat underlying causes (hypertension, heart failure, etc.)

For valvular regurgitation, the decision for intervention should be based on symptoms, ventricular function, and dimensions, with surgery recommended before irreversible cardiac damage occurs.