Mitral Insufficiency

insufficiency

[in″sŭ-fish´en-se] inability to perform properly an allotted function; called also incompetence.adrenal insufficiency abnormally diminished activity of the adrenal gland; called also hypoadrenalism.adrenocortical insufficiency abnormally diminished secretion of corticosteroids by the adrenal cortex; see also addison's disease. Called also hypoadrenocorticism and hypocorticism.aortic insufficiency inadequate closure of the valve" >aortic valve, permitting regurgitation" >aortic regurgitation.coronary insufficiency decreased supply of blood to the myocardium resulting from constriction or obstruction of the coronary arteries, but not accompanied by necrosis of the myocardial cells. Called also myocardial ischemia.ileocecal insufficiency inability of the valve" >ileocecal valve to prevent backflow of contents from the cecum into the ileum.mitral insufficiency inadequate closure of the valve" >mitral valve, permitting regurgitation" >mitral regurgitation.placental insufficiency dysfunction of the placenta, with reduction in the area of exchange of nutrients; it often leads to fetal growth retardation.pulmonary insufficiency 1. pulmonary valve insufficiency.2. respiratory insufficiency.pulmonary valve insufficiency inadequate closure of the valve" >pulmonary valve, permitting regurgitation" >pulmonic regurgitation.respiratory insufficiency see respiratory insufficiency.thyroid insufficiency hypothyroidism.tricuspid insufficiency incomplete closure of the valve" >tricuspid valve, resulting in regurgitation" >tricuspid regurgitation.valvular insufficiency failure of a cardiac valve to close perfectly, causing regurgitation" >valvular regurgitation; see also aortic, mitral, pulmonary, and tricuspid insufficiency.velopharyngeal insufficiency inadequate closure" >velopharyngeal closure, due to a condition such as cleft palate or muscular dysfunction, resulting in defective speech.venous insufficiency inadequacy of the venous valves and impairment of venous return from the lower limbs (stasis" >venous stasis), often with edema and sometimes with ulcers" >stasis ulcers at the ankle.

val·vu·lar re·gur·gi·ta·tion

a leaky state of one or more of the cardiac valves, in which the valve not closing tightly and blood is therefore regurgitating through it. Synonym(s): valvular incompetence, valvular insufficiency

val·vu·lar re·gur·gi·ta·tion

(val'vyū-lăr rĕ-gŭr'ji-tā'shŭn) A leaky state of one or more of the cardiac valves, in which the valve does not close tightly and blood therefore regurgitates through it.
Synonym(s): valvular insufficiency.

Mitral Insufficiency (Regurgitation)

DRG Category:	216
Mean LOS:	16.5 days
Description:	SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedures With Cardiac Catheterization and With Major CC
DRG Category:	218
Mean LOS:	7.4 days
Description:	SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedures With Cardiac Catheterization and Without CC or Major CC
DRG Category:	219
Mean LOS:	12.5 days
Description:	SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedures Without Cardiac Catheterization and With Major CC
DRG Category:	221
Mean LOS:	5.6 days
Description:	SURGICAL: Cardiac Valve and Other Major Cardiothoracic Procedures Without Cardiac Catheterization and Without CC or Major CC
DRG Category:	307
Mean LOS:	3.3 days
Description:	MEDICAL: Cardiac Congenital and Valvular Disorders Without Major CC

Mitral insufficiency, or mitral regurgitation, is the inadequate closure of the mitral valve, which interferes with expulsion of cardiac output from the left ventricle. The mitral valve is located between the left atrium and the left ventricle. When the heart contracts, blood is moved forward from the left ventricle out through the aortic valve and into the aorta. During the high pressures that are generated during contraction, blood flows backward through the regurgitant valve into the left atrium. Cardiac output, therefore, is separated into forward systemic flow into the aorta and backward regurgitant flow into the left atrium. The amount of forward versus backward flow depends on the severity of the mitral insufficiency and the afterload (impedance to flow against which the left ventricle pumps).

Mitral insufficiency causes an increase in blood volume in both the left atrium and ventricle. This situation occurs because of the regurgitant blood that flows from left atrium to left ventricle to left atrium again. The increased volume of blood in chronic mitral insufficiency accumulates slowly, allowing the left atrium and left ventricle to increase in size. The heart, therefore, tolerates the regurgitant blood flow without engorgement of the pulmonary circulation or reduction of cardiac output. In acute mitral insufficiency, the left atrium and ventricle are not able to tolerate the dramatic increase in blood volume, so cardiac output decreases and blood backs up quickly into the pulmonary circulation. Pulmonary congestion and acute illness follow.

Causes

Common causes of chronic mitral insufficiency are rheumatic heart disease, endocarditis, congenital anomaly, and idiopathic calcification of the mitral annulus, which inhibits valve closure. Calcification associated with aging has been found on autopsies; however, with most patients, there was a minimal functional consequence. Connective tissue diseases (Marfan’s syndrome, Ehlers-Danlos syndrome) are also associated with mitral insufficiency. Mitral valve prolapse (MVP), a common form of mitral insufficiency, occurs with degeneration of mitral leaflets, which causes a “floppy valve.” Acute mitral insufficiency can occur with myocardial infarctions that have been caused by ischemia or necrosis of the papillary muscle or by chordae tendineae that support the mitral leaflets.

Genetic considerations

Mitral insufficiency may be due to congenital valve disorders. MVP is usually considered a sporadic disorder. It can be inherited as an autosomal dominant trait with sex- and age-dependent penetrance. In addition, MVP can be seen as a feature of heritable connective tissue diseases such as Marfan’s syndrome, Ehler-Danlos syndrome, and osteogenesis imperfecta.

Gender, ethnic/racial, and life span considerations

Mitral insufficiency can occur at any age, depending on the cause. MVP is more common in females, peaks in the 30s, and is associated with a lower than normal body mass index. Chronic insufficiency increases with age and is therefore more common in the aging population. MVP is present in approximately 4% of the U.S. population and can be identified through diagnostic tests in about 20% of middle-aged and older adults. There are no specific ethnic or racial considerations known about the condition.

Global health considerations

Rheumatic fever and related mitral valve disease are more common in developing than in developed nations.

Assessment

History

Question the patient about a history of rheumatic fever because 50% of all cases of chronic mitral insufficiency are attributed to rheumatic heart disease. Because MVP, a common form of mitral insufficiency, has a familial association, determine if others in the family have the condition. Coronary heart disease contributes to both chronic and acute disorders; therefore, ask the patient if she or he has chest pain or palpitations. Determine if the patient has the classic symptoms of fatigue and shortness of breath. Other symptoms include orthopnea, palpitations, irregular heartbeat, exertional dyspnea, edema, and weight loss.

Physical examination

Inspection and palpation of the precordium are usually unremarkable except in extreme cases of mitral insufficiency. Patients may remain asymptomatic for years. Auscultation of the chest usually reveals a soft first heart sound and a systolic murmur, which is loudest at the apex. In severe mitral insufficiency, you may hear an S3 gallop. Auscultation of breathing may reveal fine crackles (rales) if pulmonary congestion is present. When the abdomen is palpated, you may note an enlarged liver if the patient has severe right-sided heart failure. The patient may also have jugular vein distention and a prominent alpha wave.

Psychosocial

In an effort to avoid exertional dyspnea and fatigue, patients usually adjust their lifestyles by restricting their activity and resting frequently. They may not notice the increasing fatigue until it gets debilitating. Assess the patient’s level of exercise and how he or she copes with activity intolerance.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Transesophageal echocardiogram	Normal mitral valve	Incompetent mitral valve	Mitral valve is incompetent, and during the systolic phase, blood flows backward into the left atrium; left-sided heart chambers may be enlarged, with an increased left ventricular end-diastolic volume
Cardiac catheterization	Normal mitral valve	Systolic regurgitant flow from the left ventricle into left atrium; left-sided hypertrophy and/or dilation of heart; may have a decreased left ventricular ejection fraction	Same as above
Doppler echocardiography	Normal mitral valve	Incompetent mitral valve	Same as above

Other Tests: Electrocardiogram may show atrial fibrillation, chest radiography, prothrombin time, activated partial thromboplastin time

Primary nursing diagnosis

Diagnosis

Activity intolerance related to diminished cardiac output

Outcomes

Energy conservation; Coping; Knowledge: Disease process; Mood equilibrium; Symptom severity; Health beliefs: Perceived control; Knowledge: Medication; Treatment regimen

Interventions

Energy management; Counseling; Exercise promotion; Hope instillation; Security management; Security enhancement; Presence; Medication management; Teaching: Prescribed diet and medications

Planning and implementation

Collaborative

Physicians place most patients with advanced mitral insufficiency on activity restrictions to decrease cardiac workload. Research suggests that if the patient is on bedrest, the use of a bedside commode creates less workload for the heart than using a bedpan. Fluid restrictions and diuretics may be ordered to reduce pulmonary congestion. Supplemental oxygen enhances gas exchange and oxygenation to decrease dyspnea and chest pain.

Most patients with mitral insufficiency can compensate or be stabilized with medical treatment for their entire lives. Surgical repair or valve replacement is considered in patients with progressive severe disease. Mitral valve repair (valvuloplasty) is preferred over replacement whenever possible. The choice of valve type is based on the patient’s age and the potential for clotting problems. Operative mortality is higher for people age 75 or older; the risks and benefits of surgery are considered on the basis of age and other disease conditions. A biologic valve (e.g., a porcine valve from a pig) usually shows structural deterioration after 6 to 10 years and needs to be replaced. A synthetic valve is more durable but is also more prone to thrombi formation. If the incompetent valve is replaced surgically with a synthetic valve, patients are prescribed long-term anticoagulant therapy, such as warfarin (Coumadin). (See Coronary Artery Disease, p. 282, for a further discussion of the collaborative and independent management of patients after open heart surgery.)

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Diuretics	Varies with drug	Thiazides; loop diuretics	Manage fluid overload and congestive symptoms
Coronary vasodilators	Varies with drug including angiotensin-converting enzyme inhibitors	Nitroglycerine, nitroprusside, captopril, enalapril, lisinopril, hydralazine	Decrease preload and afterload; decrease regurgitant blood flow; reduce ventricular size
Warfarin	Initially 10–15 mg, then 2–10 mg/day maintenance	Anticoagulant	Prevents thrombi from forming on the synthetic valve
Heparin or low-molecular-weight heparin	Initially 80 units/kg IV bolus, followed by an infusion of 18 units/kg; serial monitoring of activated partial thromboplastin time to guide future doses	Anticoagulant	Prevents thrombi initially until warfarin therapy is well regulated

Other Drugs: Inotropic agents (dobutamine [Dobutrex], digoxin) are used to enhance the heart’s pumping ability. If they are present, dysrhythmias are treated with antidysrhythmics, such as propranolol (Inderal) or quinidine. Antibiotics are used prophylactically against bacterial endocarditis and prior to interventional therapies and dental procedures (manipulation of gingival tissue, procedures on the apex of a tooth, or perforation of oral mucosa); common antibiotics are ampicillin, amoxicillin, clindamycin, gentamicin.

Independent

Maintain airway, breathing, and circulation. If the patient is stable, focus on reducing the cardiac workload and psychological stress to reduce the metabolic demands of the myocardium. Provide assistance with activities of daily living and encourage the patient to abide by activity restrictions to allow for adequate rest. Establish a quiet environment with uninterrupted rest periods, if possible. To ease the patient’s breathing, elevate the head of the bed. Encourage the patient to avoid sudden changes in position to minimize increased cardiac demand and dizziness. Instruct the patient to sit on the edge of the bed before standing.

Reduce psychological stress by approaching the patient and family in a calm, relaxed manner. Decrease fear of the unknown by providing explanations and encouraging questions. Help the patient maintain or reestablish a sense of control by participating in decisions about aspects of care. If the patient decides to have valve surgery, offer to let the patient speak with someone who already has had the surgery.

Evidence-Based Practice and Health Policy

Nardi, P., Pellegrino, A., Bassano, C., Bertoldo, F., Scafuri, A., Zeitani, J., & Chiariello, L. (2012). Mid-term outcome of mitral valve repair and coronary artery bypass grafting for ischemic or degenerative mitral regurgitation. Archives of Clinical and Experimental Surgery, 1(3), 129–137.

In a study among 111 patients who underwent surgical repair of mitral regurgitation, investigators found a lower 5-year survival rate among patients with ischemic mitral regurgitation (69%; SD, ± 7.6%) compared to patients with degenerative mitral regurgitation (87%, SD, ± 6.5%; p = 0.02). Ischemic mitral regurgitation was diagnosed in 58.6% of patients.
Ischemic mitral regurgitation was associated with a higher incidence of previous myocardial infarction, left ventricular ejection fraction < 0.45, and a greater number of diseased coronary vessels compared with patients with degenerative mitral regurgitation (p < 0.0001). However, patients with degenerative mitral regurgitation had a more severe grade of regurgitation compared to patients with ischemic mitral regurgitation (p = 0.0005).
Postsurgical echocardiograms showed resolved regurgitation in 64% of patients, minimal regurgitation in 31.5% of patients, mild regurgitation in 3.6% of patients, and moderate regurgitation in 0.9% of patients.
Surgical mortality in this sample was 7.7% (all with ischemic mitral regurgitation), and overall cardiac mortality was 9% over a mean follow-up period of 40 months (SD, ± 28 months; range, 9 to 104 months).

Documentation guidelines

Physical findings: Cardiopulmonary assessment, presence of murmurs and rales, vital signs
Response to interventions and medications: Diuretics, nitrates, vasodilators, inotropic agents, and antidysrhythmic medications
Reaction to activity restrictions, fluid restrictions, and cardiac diagnosis
Presence of complications: Chest pain, bleeding, dyspnea, wound infection

Discharge and home healthcare guidelines

Be sure the patient understands all medications, including the dosage, route, action, and adverse effects, and the need for routine laboratory monitoring for anticoagulants. Explain the need to avoid activities that may predispose the patient to excessive bleeding; hold pressure on bleeding sites to assist in clotting. Remind the patient to notify healthcare workers of anticoagulant use before procedures. Identify foods high in vitamin K, such as turnips, spinach, liver, and cauliflower, which should be limited so the effect of warfarin is not reversed. Instruct the patient to report the recurrence or escalation of signs and symptoms of mitral insufficiency. The appearance of these symptoms could indicate that the medical therapy needs readjusting or that the replaced valve is malfunctioning. Patients with synthetic valves may hear an audible click from the valve closure. The click sounds like the ticking of a watch.

Patients who have had valvular disorders or valve surgery are susceptible to bacterial endocarditis, which causes scarring or destruction of the heart valves. Bacterial endocarditis may result from dental work, surgeries, and invasive procedures, so people who have repaired or replaced heart valves should be given antibiotics before and after these treatments.

Patient discussion about Mitral Insufficiency

Q. what do you do with a broken heart? I HAD A ECHO DONE THIS WEEK AND CONCLUSION WAS: 1)SEVERE MIRTAL REGURGITATION WITH LEFT ATRIAL DILATATION 2)LOW NORMAL LV FUNCTION CHEST X RAY IMPRESSION WAS: 1)NORMAL SIZE HEART WITH PROMINENT LEFT HEART BORDER. 2)PROMINENT MARKINGS WITH PROMINENT CHANGES. 3)THE BONES ARE OSTEOPENIC. BLOOD TEST....CHEMISTRY B TYPE NATRIURETIC PEPTIDE HIGH 260A. The left atrial dilatation is likely the cause of the elevated beta natriuretic peptide. A cardiologist should be able to talk with you about dealing with the mitral valve regurgitation.

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