Mitral regurgitation (MR) is one of the most common heart valve diseases in the U.S. But lack of awareness of the severity of the disease and treatment options often leads to delays in care.
Jeremy Rier, DO, FACC, FSCAI,
Jeremy Rier, DO, FACC, FSCAI, structural heart director at WellSpan Health, breaks down why MR cases are slipping through the cracks, how we can provide earlier and more beneficial intervention, and what role PCPs can play.
Why are cases of MR going untreated?
Echocardiogram is the standard diagnostic test, but it’s hard to get solid images of the mitral valve. The valve is deep inside the chest, and its movement is complex.
Because of this difficulty, a color doppler — the most common echo parameter — is fairly subjective. The American Society of Echocardiography set quantitative echo parameters for grading mild, moderate and severe cases, including factors like PISA radius and vena contracta width. But these take a lot of skill and experience to measure, and not every team is equipped.
How can we spot more cases?
Use transesophageal echo (TEE) or MRI when echo results are ambiguous or discordant with other information. TEE and MRI both bypass the difficulties with standard echo and give you more objective data for making a diagnosis. I have a low threshold for ordering these tests — for example, if a patient’s echo appears normal but they’re struggling with serious symptoms.
The advanced cardiac imaging team at WellSpan Health is a major asset in these cases. It’s led by Ron Jacob, MD, FACC, FASE, FSCCT, FSCMR, cardiologist and medical director for advanced cardiac imaging at WellSpan York Hospital. Dr. Jacob is world-renowned and instrumental in shaping guidelines for the field. His team is closely involved when symptoms and findings don’t align, helping us determine additional imaging and get clearer results.
Ron Jacob, MD, FACC, FASE, FSCCT, FSCMR,
What are the treatment options for MR?
It depends on the type.
Functional MR: Medication first, transcatheter edge-to-edge repair if needed
Functional or secondary MR is the most common type. The valve anatomy is normal, but it malfunctions because a weak heart or atrial arrhythmia causes the chamber to enlarge and stretch the valve apart.
Treatment begins with medical management, which may improve the underlying heart condition and avoid stretching the valve.
When that isn’t effective, we recommend a procedure called transcatheter edge-to-edge repair (TEER). I go in through a vein and clip the valve leaflets together to prevent leaking. Clinical trials have shown that TEER plus medication leads to fewer hospitalizations and reduced mortality compared to medication alone.
Degenerative MR: Mitral valve repair
This type of MR occurs when the valve anatomy is abnormal. Medication won’t help in this case: The valve will always leak, and the heart will continue compensating until it can’t anymore.
Surgical mitral valve repair is the standard course following diagnosis. TEER is often an option for patients who are unfit or high risk for surgery.
When should patients get treatment?
For degenerative MR, patients should get surgery when they have symptoms or complications, such as:
- Shortness of breath and other classic symptoms of heart trouble.
- Decreased heart function.
- Complications like arrhythmia or pulmonary hypertension.
For functional MR, patients should:
- Receive medication right away.
- Be referred for evaluation if symptoms and cardiac function don’t improve within three months.
Unfortunately, I see many cases where the patient has already developed advanced heart failure. At this point, clipping the valve no longer provides as much benefit, and instead we’re talking about a ventricular assist device or other advanced treatment. Earlier referrals mean earlier treatment to help patients avoid that progression.
What can PCPs do to help patients with mitral regurgitation?
A few things:
- Be aware of the challenges with standard imaging and collaborate with cardiologists who know how and when to get objective data.
- Tell patients about TEER. It’s a good option for many people with functional MR, as well as some people with degenerative MR who might not do well with open surgery.
- And the biggest one: Don’t wait too long to refer patients with functional MR. If they don’t improve with medicine, let’s see if TEER can help.