Prakash Chandran (Host): Welcome to BayCare HealthChat. I'm your host Prakash Chandran. And in this episode we're going to explore causes, symptoms and diagnosis of mitral valve regurgitation, as well as the preventative measures and treatment options available to those affected. Joining us to discuss is Dr. Joshua Rovin. He's the Director of the Structural Heart and Advanced Valve Care Center at Morton Plant Hospital and Cardiovascular Surgeon with BayCare Health System.

Dr. Rovin, thank you so much for joining me today. I truly appreciate your time. I wanted to get started with the basics. What exactly is mitral valve regurgitation?

Joshua Rovin, MD: Prakash, my pleasure. Thanks for having me. Mitral regurgitation is when the mitral valve, which is the two flapped valve that's between the left-sided collecting chamber, which is the left atrium and the left-sided pumping chamber, which is the left ventricle, is no longer competent. Meaning that instead of closing all the way, it's allowing blood to leak back into the left-sided collecting chamber.

Host: And when that happens, what exactly does that cause? Like what types of symptoms does the patient experience?

Joshua Rovin, MD: Yeah, so a lot of times, it's not noticeable initially because these symptoms can evolve slowly and as the condition progresses, they can start to develop shortness of breath. Patients can have heart palpitations and develop dysrhythmia such as atrial fibrillation. They can start having swelling of their lower extremities, their hands, their feet and they can also feel fatigued.

Fatigue's one of the trickiest symptoms because obviously there are a lot of different things that cause fatigue, but I would say shortness of breath and swelling tend to be the most common symptoms.

Host: Okay, interesting. So because it can represent as so many different things, how do you actually go about diagnosis and really knowing that it is mitral regurgitation?

Joshua Rovin, MD: So a lot of times patients will come in to their primary care doctor or to their cardiologist and they, they've been referred because they exhibit those symptoms. And then when you examine them, you may note that there is a murmur. And that murmur based off of where we listen on the chest, you can say, ah, that's a murmur of mitral regurgitation.

One of the most common causes we hear is people talk about mitral valve prolapse. A lot of patients say, Hey, I've had a history of mitral valve prolapse which is very common and tends to be when one of the valve flaps bulges into that left atrium or that left-sided collecting chamber when the heart contracts.

And so that prevents, that little bulging can prevent the valve from closing tightly, and people can live with that for a very, very long time. But after a while, those leaflets can stretch or change shape, increasing the amount of leakiness. And so the most common cause that we hear when we're diagnosing this is someone who comes in and has a murmur.

Host: Got it. So does a patient usually represent with a murmur or could there be a lack of murmur, but still the mitral regurgitation?

Joshua Rovin, MD: Yeah, I would say the answer to that is yes. It's a little more complicated than that, but yes, you can come in, usually the first place where we see mitral regurgitation that's significant or that we can pick up is using an echo. So when we question whether people have valve problems or not, a lot of times one of the first tests that's performed, after a physical examination is a transthoracic echo.

And on a transthoracic echo, that's where they take the probe and they put some gel on your chest and they look using sound waves and interrogate the heart. And you can look at the heart's function. You can look at the size of the chambers, you can look at the valves, and you can determine whether the valves are leaking or narrowed. And so that's very helpful. And a lot of times after you have a transthoracic echo, which is a pretty straightforward screening echo, really what you want to do is you want to make sure if your doctor is concerned about this, that you are referred to a center that does a lot with mitral regurgitation or mitral valvular disease because the mitral valve is very complicated. And in general, it's best treated by a multidisciplinary team.

Host: Yeah. So before we get into the treatment piece of it, I was wondering if you could share how common mitral valve regurgitation is in the US.

Joshua Rovin, MD: It's pretty common. It's one of the most common valve problems that there is. And again, there are different types of regurgitation. And most of the time when we see patients, we see this as a result of just chronic degeneration of the mitral valve, and we call that primary mitral regurgitation.

But that is actually when the problem is with the mitral valve. You can also have a problem with the valve when the pumping chamber or the ventricle starts to become abnormal and dilate. Unlike an aortic valve or a pulmonary valve, the mitral valve leaflets are attached by cords or strings to muscles on the heart wall that are called papillary muscles.

And those papillary muscles are attached to the pumping chamber. And so, mitral regurgitation can be a very dynamic process, and it's possible to have a leaky valve with a totally normal valve, but an abnormal ventricle because as the ventricle changes size and enlarges, if you think about it, the door frame itself, where those saloon doors or those two flaps can actually enlarge, and then you get a draft, if you will, between the two flaps. And then the other thing that can happen is if the ventricle dilates and stretches out, you can have the leaflets or the flaps pulled downward because of the stretching on the actual cords.

Host: Yeah, I can see that there are just so many variables at play here, but you know, tell me, is there a demographic that mitral regurgitation affects more than others? And also, if you could speak to the risk factors that would be great as well.

Joshua Rovin, MD: Sure. So, there are multiple causes of a leaky mitral valve. Again, it can be degeneration of the valve, it can have progression from prolapse, it can be the result of coronary artery disease where the muscle itself is damaged, it can be the result of a congenital heart defect. It can be the result of infection, where infection actually damages the valve. So once patients are diagnosed with a mitral problem or mitral regurgitation, they should find themselves a center that addresses this with a team and it's a complex process where you go through the whole diagnostics, which tend to include an EKG, a transthoracic echo, a transesophageal echo, which is really the next step. That's where the cardiologists put the echo probe in your esophagus, so down your mouth, just like they would do if they're looking in your stomach like for an ulcer or something like that. This is called a transesophageal echo, and that allows us to get very, very specific pictures of the heart, the heart muscle, the valvular structures and figure out is this just an isolated mitral problem or are there other valves, or is the actual heart muscle involved in the process?

Host: Very interesting. Now, you know, we started talking a little bit about treatment before. Maybe you can touch on that. So let's say it's identified that you do have mitral regurgitation. You go to a specialty center, what does treatment look like?

Joshua Rovin, MD: So once you've had the diagnosis, I think based off of what type of regurgitation you have, then determines the type of treatment strategy. So let's say for instance you have mitral valve prolapse, which has progressed over time and now you have one of the flaps is prolapsing up too far. Depending on your age and risk factors, we know that mitral valve repair surgery is the best option. That's the gold standard by which we look to treat mitral regurgitation. And so no one wants to have surgery, but that's the tried and true treatment to be able to repair a valve and have a durable long-term fix. Sometimes valves can't be repaired. And then they need to be replaced. And that's a discussion. Sometimes we replace those valves with what we call bioprosthetic valves or valves made of animal parts. And other times we replace the valve with a mechanical valve, and that's a valve that's made of a carbon fiber or actual metallic material depending on the patient's age and the disease process.

The other thing is sometimes this is, as we talked about, the result of the muscle itself being dilated. And so a lot of times in those circumstances, the initial treatment is with medication and treating the heart failure, and sometimes even using a pacemaker or resynchronization therapy to improve the function of the actual left ventricle. And when you do that, the mitral regurgitation can completely go away.

Host: Wow. Yeah. You know, it's so interesting hearing you talk about this because like you said, it's so dynamic. There are a number of things that could potentially lead to mitral regurgitation, but there also seems like it's like treatment is dynamic as well, right? Like you could do that mitral valve repair surgery, but sometimes the pacemaker is involved to let it kind of kickstart itself again. It really is just fascinating hearing the dynamism of this disease.

Joshua Rovin, MD: Yeah. And, I think this is one of the key points that we were talking about earlier, Prakash, which is, you need to be at a center that has all the tools in the toolbox. When you deal with the mitral valve, which is a very complicated, you know, has a, a complicated physiology and a complicated pathophysiology, you need to have all the tools.

And we touched a little bit about surgery to repair the valve. Or surgery to replace the valve. The other great news is that as technology has progressed, we now have transcatheter therapies and these are therapies that can repair the valve. The most common of which today is the repair strategy called TEER.

Or T-E-E-R, which is transcatheter edge to edge repair. And that's basically where we use a clothespin like structure clip, either called PASCAL or MitraClip to actually bring the two leaflets together. This is done still under general anesthesia, but with a catheter that we put through the femoral vein.

And the beauty of that is it's a much less invasive procedure and most patients are able to go home from the hospital the next day. The other tool in the toolbox, which is still being studied and is part of some trials, is called transcatheter mitral valve replacement, and that's where we either use a catheter that we put in through the groin vein or sometimes through a small incision on the chest and are able to actually replace the mitral valve, but without using cardiopulmonary bypass and opening the chest up fully.

These are not approved by the FDA, these replacement strategies that I was just speaking of, but again, being at a center that has those types of adjuncts in their toolbox is really important.

Host: So just as we start to close, I think one thing that people might be wondering is if someone suffers from mitral regurgitation, is it indicative that they're, for example, more likely to get or have other structural heart conditions or cardiac conditions?

Joshua Rovin, MD: No, I don't think that's necessarily true. I mean, I think the key is if you're diagnosed with a mitral valve problem, ultimately you want to find yourself at a center that has a multidisciplinary team that treats and takes care of lots of patients with mitral valve disease. Again, that type of center is usually has a multidisciplinary team with echocardiographers, cardiologists, heart surgeons, electrophysiologists, heart failure doctors, and then have a toolbox that includes both commercially available products such as repair and replacement surgeries, and repair transcatheter techniques, but also a toolbox of strategies that are part of up and coming trials and up and coming techniques that probably won't be available mainstream for another five or 10 years.

Host: Well, this has been a fascinating conversation, Dr. Rovin. I really appreciate your time. Is there anything else that you would like to leave our audience with before we close?

Joshua Rovin, MD: No, I think Prakash this has been great. I think again, the key for patients is if you do have mitral regurgitation or you've been diagnosed by that, you know, try and get yourself seen and evaluated at a center that does a lot of mitral valve work and has a good multidisciplinary team.

Host: I think that is fantastic advice. Well thank you again for your time, Dr. Rovin. Really appreciate you.

Joshua Rovin, MD: Thank you, Prakash, for this opportunity.

Host: That was Dr. Joshua Rovin, Director of the Structural Heart and Advanced Valve Care Center at Morton Plant Hospital and Cardiovascular Surgeon with BayCare Health System. That wraps up this episode of BayCare HealthChat.

Head on over to our website at BayCareHeartValve.org for more information. Please remember to subscribe, rate, and review this podcast and all other BayCare podcasts. For more health tips and updates, you can follow us on your social channels. Thanks again for listening. My name is Prakash Chandran. Stay well.