Mitral Valve Regurgitation
The mitral valve separates the two left chambers of the heart: the left atrium and the left ventricle. Mitral regurgitation (MR) is the leakage of blood backward through the mitral valve caused by the leaflets not meeting each time the left ventricle contracts.
A leaking mitral valve allows the blood to flow in two directions during the left ventricle contraction. The blood flows from the ventricle through the aortic valve as it should while some blood flows in the reverse direction back into the atrium. The backflow of blood through the valve leads to an inefficient system.
Mitral valve leaflets do not meet, allowing blood to flow back into the left atrium.
Having mitral valve regurgitation does not necessarily mean you will perceive the symptoms associated with the condition. Mild mitral regurgitation may not have any symptoms. When regurgitation is more severe, symptoms begin to develop. The left ventricle enlarges as it pumps more blood to maintain the forward flow of blood. The regurgitation can also increase blood volume and pressure in the left atrium. The increased blood pressure in the left atrium can increase pressure in the veins leading from the lungs to the heart (pulmonary veins). When this becomes severe, increased pressure may result in congestion (or fluid build-up) in the lungs.
Patients may have no symptoms for decades and be unaware that they have this condition. Mitral valve regurgitation is often first suspected when your doctor hears a heart murmur. Sometimes, problems develop quickly and patients may experience a sudden onset of signs and symptoms.
shortness of breath especially during exertion
swelling in legs, ankles, and abdomen
palpitations; sensation of a rapid and fluttering heartbeat
pulmonary edema or the filling of fluid in lungs
congestive heart failure
Causes: Why do I have MR?
Degenerative MR (DMR, also known as primary or organic MR) is usually due to an anatomic abnormality of the mitral valve. That includes the leaflets and the cord muscles that attach the valve to the ventricle.
Functional MR (also known as secondary MR) is the result of left ventricular dilation which can be secondary to heart attacks, myocarditis or weakening of the heart muscle. When the left ventricle is dysfunctional, it leads to annular dilation and incomplete coaptation (meeting of the leaflets) of the mitral valve resulting in mitral regurgitant.
Next Steps: Investigation Plan
Your physician will organize some investigations. These investigations are important so that an informed decision can be made in regards to future treatment. One or more of the following diagnostic procedures may be considered for a diagnosis:
Transthoracic Echocardiogram (TTE)
An echocardiogram (ultrasound of your heart) is one of the most commonly used diagnostic tests for mitral valve regurgitation. It is a test that uses sound waves to evaluate the mitral valve to assess the severity of mitral regurgitation.
An ECG involves the attachment of electrodes to the chest in order to measure the electrical impulses of your heart. It can detect abnormal heart rhythm, and determine any abnormal enlargement of heart chambers and if there is any ischemic heart disease.
Transesophageal Echocardiogram (TEE)
A TEE is a test where a probe (similar to the camera used to look at the stomach) is carefully inserted into your esophagus. The doctor will be able to have a closer look at the mitral valve than with the transthoracic echocardiogram. There will be many pictured taken to measure the detailed structure of your mitral valve and assess how it is functioning. This test will allow the team to determine if the minimally invasive MitraClip or mitral valve surgery is best for the patient.
Heart Catheterization (Angiogram)
A heart catheterization is an invasive investigation done prior to transcatheter mitral valve repair to assess the pressure in the heart as well as to evaluate the coronary arteries (blood vessles that give the heart blood) that could affect the future management of your condition.
Chest Radiography (Chest X-Ray)
A chest x-ray may be done to look for enlargement of the heart, and fluid in the lungs that may be suggestive of mitral regurgitation.
You need to speak with at least 1 member of the MitraClip team (by phone or in person). You may have a clinic appointment booked with a cardiologist, a cardiac surgeon, a nurse practitioner or all three.
All of these appointments are booked after the clinical nurse coordinator speaks with you, reviews the process and collects your health information
We send all of your upcoming appointment information (times and dates) to an email address you provide or by mail
The time from referral to procedure varies depending on your health and booking availability. We will keep you updated on your progress every step of the way
The Heart Team
Click "Meet the Team" to learn more.
At Toronto General Hospital’s Peter Munk Cardiac Centre (PMCC), we believe that a multidisciplinary team improves patient care. This ‘Heart Team’ consists of professionals with a high degree of specialization, that have been brought together to deliver the best possible care for our patients. It consists of the Interventional Cardiologists, Cardiothoracic Surgeons, Cardiac Anesthesiologists, Radiologists, Echocardiologists, echo sonographers and specialized nurses. Once your tests are completed, your case will be discussed by the Heart Team at our conference where all of your clinical data is presented, including results from the diagnostic imaging tests.
The Heart Team will come to a consensus about the most reasonable course of action for your specific case taking into account all of your clinical features. The outcome of this discussion will be reviewed with you afterwards.
Based on the investigation, the Heart Team may recommend various different treatment options. If valve replacement is required, one of two treatment routes will be considered.
Open Heart Surgery
For patients with mitral regurgitation, open heart surgery is generally recommended to repair or replace the mitral valve. Mitral repair is always preferred when possible. In expert hands, the results are excellent. This involves opening the chest, temporarily stopping the heart while using a heart-lung machine. If the valve cannot be repaired, the old valve is excised and a new valve made from metal or animal tissue is sutured in. While this method is effective in replacing the valve, usually after surgery, patients spend 4-7 days at hospital and it may take approximately 6 months to fully recover from surgery.
Some patients with mitral valve regurgitation are categorized as inoperable because they may not be able to survive surgery. For them, mortality rates increase if they do not receive treatment. This presents a significant healthcare challenge.
Thankfully in patients who are inoperable, MitraClip has proven to be incredibly effective. Patients who cannot have surgery have improved outcomes, as compared to treatment with medication alone.
Transcatheter Mitral Valve Repair (TMVR): MitraClip
In patients considered too high risk for surgery, the mitral clip provides an opportunity to reduce the degree of mitral regurgitation and may help to reduce symptoms.
The procedure is done under general anaesthesia. A cardiac catheter is advanced up to your heart with x-ray guidance. The catheter is a thin, flexible tube which is inserted through a venous access, and is guided to the location of the mitral valve in the heart. Your doctor guides the catheter, which contains the MitraClip device, by using x-ray and echocardiography (ultrasound of the heart).
The catheter must cross from the right atrium to the left atrium. To facilitate this, a little hole is made within the septum using needles and a catheter through the same venous access.
Then, the MitraClip device is passed through your mitral valve, just past it’s leaflets, entering your left ventricle.
The MitraClip is then opened and grabs both leaflets of your mitral valve. The surgeon or cardiologist
will then close the clip on the leaflets. Fastening the clip to the leaflets decreases regurgitant blood. The catheter is then removed. During the procedure, your heart will continue to beat on its own. A heart or lung bypass machine is not needed.
The recovery period is generally within several days and you will be discharged within that period. Over time, your tissues will grow over the device and it will become a part of your heart. You will generally have an improvement of symptoms and quality of life.
Your cardiologist will provide full written guidelines in terms of activities and medications. It is important to follow these guidelines, and adhere to the prescriptions. A follow-up appointment will be scheduled 2-3 months post-procedure to ensure a safe and smooth recovery. During the visit, you will have an echocardiogram monitor the clip that has been placed and the progress your heart has made. Your doctor will decide at this time whether you should return to your own doctor for follow up or whether further follow up is required.
What can I do while waiting for my procedure?
There are a few things you can do to while you are waiting for your Mitral Valve intervention.
1. Learn more about the process:
Review the education booklet once you receive it from the Nurse Coordinator
Write down questions and email or call our office to review with the Nurse Coordinator
If you have someone who will be supporting you during this process make sure they also have this information and our number to go over any questions
2. Keep healthy with ongoing medical care:
Your family doctor or primary health care providers are responsible for your medical care while you are waiting for the procedure
Continue to see them for your regular medical care
Continue to see specialists for your heart and other medical conditions
What can I expect for my recovery?
Check your insertion site every day. If you notice any of these warning signs, see your family doctor.
What is normal?
slightly red, swollen and tender
a bit lumpy or bumpy
occasional clear drainage
pain gets better gradually
What are warning signs?
any area of redness or swelling that does not get better
a lump that is getting bigger
yellow or pink drainage
pain does not get better or is severe
fever – a temperature of 38.5 °C (101 °F) or higher
bleeding from the puncture site that does not stop
If you are worried, call your family doctor first or call the MitraClip office at 416 340 4800 ext. 6153 or 6803.
Living with MR: Frequently Asked Questions
Will I need any further treatments following treatment?
Your cardiologist will provide full written guidelines in terms of activities and medications. It is important to follow these guidelines, and adhere to the prescriptions. A follow-up appointment will be scheduled 2-3 months post procedure to ensure a safe and smooth recovery. During the visit, you will have an echocardiogram monitor the clip that has been placed and the progress your heart has made. Your doctor will decide at this time whether you should return to your own doctor for follow up or whether further follow up is required.
Do I need new medication after the procedure?
There may be some changes to your medications after your procedure. The cardiologist caring for you on the floor will include this in the list of your discharge instructions.
How urgent is the treatment?
Once you are symptomatic, it is advisable to receive medical treatment as soon as possible.
Who is a candidate for TMVR in Ontario?
Presently, patients who are inoperable or high risk for open-heart surgery are referred to the structural heart program for consideration of MitraClip or other devices that are part of clinical trials that we are involved in.
Will OHIP (public insurance) cover my procedure?
What are the chances that the TMVR will fail?
Patients who present a good result after a year, generally have had a durable repair. However, presently there is very little evidence of premature TMVR failure. Surgery provides a repair with less mitral leaking.
When is intervention preferable to surgery?
MitraClip is only recommended for high-risk patients who are unable to undergo open-heart surgery at this time. This is due to the minimally invasive nature of the procedure, which poses a reduced risk to the patient, as compared to open-heart surgery.
In some cases, surgery may be the only option.
Can I undergo MRI after my procedure?
Yes, you can go through MRI investigations safely. The clip is MRI conditional.
Can I go through airport security checks?
Yes, you can. Your MitraClip will not trigger the alarm.
Are there any lifestyle restrictions following the procedure?
In general there are no lifestyle restrictions, however, activities such as contact sports should be avoided immediately post-procedure.
What activities are safe?
Before the procedure, your physical activity may have been very limited. After your procedure, you can expect to feel tired and take rests often. As you get stronger and more confident, you can gradually increase your activity
Walking and or moving your body is important for your recovery. During the first week at home try walking around your space or taking a short walk outside each day. Then, gradually increase your activity by walking a little longer each day
Until your follow-up appointment, please take it easy. Do not lift or carry anything heavy such as a bag of groceries. Avoid strenuous activities such as gardening, vacuuming and swimming
When you can return to work will depend on the type of job you do and your recovery. Please discuss your plans to return to work with your cardiologist or at your follow-up appointment
We will give you written discharge instructions specifically for you before you leave the hospital. Your instructions will include all of the things you
should do and not do when you go home or to your next place of residence. Please make sure you read and understand the discharge instructions before you leave the hospital.
Should my health care providers know that I have had a procedure for my Mitral Valve?
Yes, tell all your care providers that you had your procedure.
• Your family doctor and any other doctor you see
• Your pharmacist
• Your physiotherapist, visiting nurses and home care providers
You may also wish to wear medical identification to let health care providers know that you have an artificial heart valve. You can order Medic Alert products (such as bracelets, necklaces or watches) from Medic Alert Foundation Canada at 1 800 668 1507 or www.medicalert.ca
When do I need follow-up appointments?
You should have a follow-up appointment with your regular cardiologist about 2 months after your procedure unless otherwise instructed when you are discharged form the hospital. You may also need an echocardiogram as part of this follow up.
When to get Medical Help
Call 911 or go to your nearest Emergency Department
if you have ANY of the following:
Sudden chest pain
Sudden shortness of breath
Irregular heart rate
Loss of vision
Numbness or weakness in your legs more than usual
Call your family doctor if you have any of the following:
A lump that is getting bigger or increasing pain at your insertion site
Fever – a temperature of 38.5 °C (101.3 °F) or higher
Signs of skin infection – any area that has swelling, redness, warmth or
drainage (yellow or pink fluid)
Signs of a bladder infection – burning, sudden urge to pee, urine that is cloudy or smells bad, back pain
You feel ill and are concerned
Once you leave the hospital, your regular doctors will provide your health care.
How do I keep my heart healthy?
To stay healthy it is important to prevent germs such as bacteria from entering your body. Bacteria can get into your blood if you have an infection or wound in another part of your body. For example, if you have an infection in your mouth or on your skin, bacteria can easily get into your blood. The bacteria can cause a serious infection that damages your heart tissue and valves.
A healthy mouth:
Do not have any dental work (cleaning or treatment) for 6 months after your TAVI procedure, unless you have a tooth ache or abscess. Visit your dentist twice a year after your MitraClip procedure. Tell your dentist that you had a MitraClip procedure.
For more information about healthy eating:
• Read UHN’s pamphlet “Your Heart and Sodium (salt) Restriction” Visit www.uhnpatienteducation.ca
• Visit the Dietitians of Canada website: www.eatrightontario.ca
• Enter ‘salt’ in the search box for a list of helpful articles
• Speak with a Registered Dietitian for free at 1 877 510 5102
One of the best ways for you and your family to stay healthy is to wash your hands often. But keep your skin clean and dry. Check for any breaks or cuts in your skin.
How do I get referred to Toronto General Hospital’s Peter Munk Cardiac Centre (PMCC)?
You need a referral from your cardiologist to be considered for a MitraClip or Mitral Valve surgery. The office will only be able to discuss your care with you after your referral has been received and reviewed by one of the Mitral Valve doctors.
Please find our referral form here:
PREPARING FOR YOUR
Thorough preparation before a diagnostic test or interventional procedure is essential.
Learn how to prepare for your specific appointment by clicking one of the options below:
Questions? Call Our Office!
Phone: 416 340 4800, extension 6153
Questions? Call our Office!
MitraClip Program Office
Toronto General Hospital
200 Elizabeth Street – Eaton South (Room 223) Toronto ON M5G 2C4
Phone: 416 340 4800 extension 6153 or 6803 | Fax: 416 340 5143