Getting to the Heart of the matter: chronic mitral valve regurgitation in the mature athlete

Mitral regurgitation (MR) is a relatively common heart valve disorder that can arise either as a primary disorder of the valve itself or secondarily from various forms of cardiomyopathy. In either case, the result is the same: a portion of the outward blood flow of the heart backs up into the left atrium (see image above). This reduces the amount of oxygenated blood delivered to the body and congests the vasculature of the lungs. For athletes suffering from MR, this can impose significant limitations on stamina and performance.

MR can manifest acutely after an infection or heart attack, causing severe symptoms such as profound fatigue, shortness of breath, pulmonary edema, and shock. Acute MR is a medical emergency, often requiring hospitalization and aggressive intervention. MR can also be gradual, insidious and chronic, progressing to symptoms of heart failure and arrhythmias such as atrial fibrillation. Chronic MR poses a unique challenge to both the athlete suffering from it and the physician who is managing care.

Staging of chronic MR is based on symptom severity, anatomy of the valve itself, the size and function of the left heart, and whether or not blood pressure in the pulmonary vasculature is elevated. If your physician suspects that you may have this valvular disorder based on your symptoms and clinical exam, diagnosis and staging is made by echocardiography. It is important here to let your physician know your level of athletic performance, as even mild or moderate symptoms can significantly limit your ability to exercise. Additional testing including an EKG stress test, blood work, and possible heart catheterization may be performed to determine the ultimate cause of your MR. Medical management of MR is aimed at reducing symptomology and mitigating risk factors that contribute to its progression. Adequate blood pressure control with lifestyle modification and medications is of the utmost importance. Once diagnosed and properly characterized, those with MR should be monitored at least annually. Timing of repeat echocardiography is dictated by symptom severity or when symptoms worsen.

Ultimately, MR requires surgery to correct. Evidence shows that when done earlier, before the onset of symptoms, successful repair or replacement of the diseased mitral valve significantly improves symptoms and mortality. Candidates for surgical intervention are based on staging of disease and severity of symptoms. Typically, surgery is done only for patients with severe valve abnormalities and symptoms that limit activities of daily living, including exercise and competitive sports. However, because each patient varies in their level of fitness, what is typically defined as moderate for some may be severe to others. Therefore, the decision to proceed with surgery should be individualized for every patient, taking into account their baseline level of fitness and overall quality of life.

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References:

Yiu SF, Enriquez-Sarano M, Tribouilloy C, et al. Determinants of the degree of functional mitral regurgitation in patients with systolic left ventricular dysfunction: A quantitative clinical study. Circulation 2000; 102:1400.

Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2017.

Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005; 352:875.