Elsevier

The Lancet

Volume 387, Issue 10025, 26 March–1 April 2016, Pages 1324-1334
The Lancet

Series
Mitral valve disease—current management and future challenges

https://doi.org/10.1016/S0140-6736(16)00558-4Get rights and content

Summary

The field of mitral valve disease diagnosis and management is rapidly changing. New understanding of disease pathology and progression, with improvements in and increased use of sophisticated imaging modalities, have led to early diagnosis and complex treatment. In primary mitral regurgitation, surgical repair is the standard of care. Treatment of asymptomatic patients with severe mitral regurgitation in valve reference centres, in which successful repair is more than 95% and surgical mortality is less than 1%, should be the expectation for the next 5 years. Transcatheter mitral valve repair with a MitraClip device is also producing good outcomes in patients with primary mitral regurgitation who are at high surgical risk. Findings from clinical trials of MitraClip versus surgery in patients of intermediate surgical risk are expected to be initiated in the next few years. In patients with secondary mitral regurgitation, mainly a disease of the left ventricle, the vision for the next 5 years is not nearly as clear. Outcomes from ongoing clinical trials will greatly inform this field. Use of transcatheter techniques, both repair and replacement, is expected to substantially expand. Mitral annular calcification is an increasing problem in elderly people, causing both mitral stenosis and regurgitation which are difficult to treat. There is anecdotal experience with use of transcatheter valves by either a catheter-based approach or as a hybrid technique with open surgery, which is being studied in early feasibility trials.

Introduction

Mitral valve disease is the most common of the valvular heart disorders, particularly in ageing populations, with a prevalence of more than 10% in people aged older than 75 years.1 Mitral regurgitation is divided into either primary (a structural or degenerative abnormality of the mitral valve apparatus) or secondary (a disease of the left ventricle, which interferes with the function and integrity of the mitral valve apparatus) mitral regurgitation (table).2, 3 Mitral stenosis is usually due to rheumatic disease, but heavy calcification of the mitral annulus with extension into the leaflets might cause obstruction to left ventricular inflow, particularly in the elderly population.2, 4

Treatment of these various valve disorders is dependent on the underlying cause, pathophysiology, and natural history of each disorder. This Review highlights the clinical presentation, diagnosis, and current and future management for patients with primary mitral regurgitation, secondary mitral regurgitation, and mitral stenosis due to annular calcification. A separate report on rheumatic heart disease will cover rheumatic mitral stenosis.5

Section snippets

Causes, pathophysiology, and natural history

The most common cause of primary mitral regurgitation is degenerative mitral valve disease, in which there is myxomatous degeneration of the mitral valve leaflets and elongated and redundant chordal apparatus.6 Thickened redundant leaflets will prolapse back into the left atrium causing malcoaptation of leaflet edges and subsequent regurgitation. Rupture of chordal structures is not uncommon in patients with mitral regurgitation, especially in older men, which will then cause a further increase

Causes, pathophysiology, and natural history

Secondary mitral regurgitation is mainly a disease of the left ventricle. Mitral regurgitation occurs when the mitral valve leaflets are normal, but left ventricular dilation results in leaflet tethering and annular dilation that prevents coaptation.54 Secondary mitral regurgitation includes both ischaemic and non-ischaemic functional mitral regurgitation causes. Studies54, 55 have shown adverse outcome at a smaller calculated regurgitation orifice area than for primary mitral regurgitation. A

Causes, pathophysiology, and natural history

Mitral annular calcification is a chronic degenerative condition of the fibrous mitral annulus, resulting in progressive calcification, particularly involving the posterior annulus.68 The estimated prevalence of mitral annular calcification is 10% of elderly patients, with 1–2% of whom develop stenosis.68, 69, 70 Risk factors for mitral annular calcification include older age, being a woman, having chronic kidney disease, and diseases predisposing to left ventricular hypertrophy (ie,

Conclusions

The field of mitral valve disease diagnosis and management is rapidly developing. New understanding of disease pathological changes, improvements, and wider uptake of sophisticated imaging modalities (including three-dimensional echo, four-dimensional CT, and cardiac magnetic resonance) are providing new insights leading to early diagnosis and complex treatment. In primary mitral regurgitation, surgical repair—often through minimally invasive approaches—is becoming the more commonly used

Search strategy and selection criteria

We searched Embase, PubMed, MEDLINE, and the Cochrane Library for reports published between Jan 1, 2005, and Feb 15, 2016. We used the search terms “mitral valve”, “mitral regurgitation”, “mitral annular calcification”, “mitral valve repair”, “mitral valve replacement”, and “mitral stenosis”, which we combined with many search terms for “pathophysiology”, “epidemiology”, “natural history”, “diagnosis”, “management”, and “current issues”. We focused on the latest publications, but did not

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