Mitral regurgitation: symptoms, causes, tests and treatment

The heart has four valves that act like one-way doors, keeping blood moving in one direction. The British Heart Foundation explains that valve regurgitation, also called a leaky valve, means the valve does not close fully and blood can leak back into the heart. The mitral valve sits on the left side, between the upper and lower chambers, so a leak sends blood backwards from the pumping chamber into the chamber above.

The NHS adds that heart valve disease makes the heart work harder to pump blood round the body, and that it can affect any of the four valves but is most common in the aortic or mitral valves on the left. Valve prolapse, where the valve becomes floppy and does not close properly, is one way a leak can arise, according to the BHF.

Doctors describe the leak as mild, moderate or severe. The BHF says treatment is different at each level, and NICE guidance uses the British Society of Echocardiography definitions of severity.

The NHS lists shortness of breath, feeling tired or weak, dizziness, heart palpitations, swollen ankles and feet, and chest pain or discomfort. Some people have no symptoms. The BHF adds that doctors may hear a heart murmur, a swishing sound, with a stethoscope, which can be a sign of a valve problem.

The NHS advises seeing a GP if you are regularly short of breath, feel tired, weak or dizzy during normal activities, have palpitations that keep coming back, last longer than a few minutes or are getting worse, have swollen ankles or feet, or have chest pain that comes and goes. It adds that these can have many causes, so having them does not definitely mean valve disease.

The BHF advises contacting your doctor for an urgent appointment if symptoms are getting worse, there are new symptoms, you have a temperature with no obvious reason, sweating especially at night, weight loss for no clear reason, or have felt unwell for two to three weeks. Because endocarditis is a known complication of valve disease, an unexplained fever deserves attention.

The NHS lists causes of heart valve disease generally: being born with the condition, changes to the heart with age, particularly with smoking, high blood pressure or high cholesterol, conditions that affect the heart such as rheumatic fever, cardiomyopathy or endocarditis, and damage from a heart attack. The BHF gives similar main causes, including an abnormal valve from birth, rheumatic fever, heart muscle disease, damage after a heart attack, getting older and infection of the heart (endocarditis).

NICE separates mitral regurgitation into primary (arising from the valve itself) and secondary forms, and discusses the secondary type alongside heart failure. In practice the cause shapes the treatment, which is why an echocardiogram and specialist assessment matter.

The NHS says a GP will listen to your heart and may arrange tests or refer you to a cardiologist. Tests may include an echocardiogram, a chest X-ray and an ECG. The BHF adds blood tests, cardiac CT, cardiac MRI and angiogram as possible further tests, and says the echocardiogram is the most common test, with several types.

NICE gives guidance for a GP who hears a murmur. It says to consider an echocardiogram for adults with a murmur and no other signs if valve disease is suspected from the nature of the murmur, family history, age or medical history, and to offer one if the murmur comes with signs or symptoms such as ankle swelling, angina or breathlessness, or an abnormal ECG. Urgent specialist assessment, including an echocardiogram, within 2 weeks is advised for a systolic murmur with fainting on exertion, and is considered for a murmur with severe symptoms such as breathlessness on minimal exertion or at rest.

NICE advises referral to a specialist for adults with moderate or severe valve disease of any type.

The NHS says that if you have symptoms or severe disease you may need medicines, and lists ACE inhibitors, diuretics, medicines that slow the heart rate such as beta blockers, and anticoagulants to reduce the risk of blood clots. The BHF says medicine can reduce the heart's workload and improve symptoms, may be offered if the disease is mild, getting worse or surgery is not an option, and that surgery either repairs or replaces part or all of the valve. These decisions belong to your cardiology team.

NICE offers more detail for mitral regurgitation. It says to offer an intervention to adults with symptomatic severe valve disease. For severe primary mitral regurgitation with an indication for repair it advises surgical repair, by median sternotomy or minimally invasive surgery, if surgery is suitable, and valve replacement if the valve is not suitable for repair. Where surgery is unsuitable and symptoms persist, transcatheter edge-to-edge repair can be considered. For severe secondary mitral regurgitation, repair or replacement is considered when someone is having cardiac surgery for another reason, medical management is offered to people with heart failure if surgery is unsuitable, and transcatheter edge-to-edge repair is considered if they stay symptomatic on medical management.

For people without symptoms, NICE says referral for intervention can be considered when severe primary mitral regurgitation comes with features on testing, such as a left ventricular ejection fraction under 60%, an end-systolic diameter above 45 mm, or raised pulmonary artery pressure on exercise testing. These thresholds are for clinicians; a cardiologist can explain what your own measurements mean.

The NHS describes valve surgery as repair if the valve is not seriously damaged, or replacement with an artificial valve or one made from human or animal tissue if it cannot be repaired.

Mild disease with no symptoms may need no treatment. The BHF says doctors usually suggest check-ups including an echocardiogram every 3 to 5 years, and most people with mild disease have long lives. For moderate or severe disease without symptoms the BHF advises a check-up and echocardiogram every 6 to 12 months, and says new or worsening symptoms mean making an appointment.

On lifestyle the BHF recommends exercising in a safe way, keeping to a healthy weight, a balanced diet, stopping smoking and reducing alcohol. It says you may need to avoid activities where you strain or hold your breath, for example heavy lifting, weight training or swimming, and that you should check what is safe for you with your doctor or nurse specialist. The NHS says the care team will advise on changes, which can include avoiding strenuous exercise.

The BHF suggests questions to ask your team about exercise, diet, work, holidays and flying, contraception and sex, driving, having children, antibiotics and the dentist, and support available.

The NHS says it is important to get advice from a heart specialist if you are pregnant or want to get pregnant, because pregnancy can make heart valve disease symptoms worse. It says you can usually have a safe pregnancy, but you may need extra monitoring and treatment. NICE and the BHF indicate that most women with valve disease can have a pregnancy without complications, and NICE advises referral to a cardiologist with relevant expertise for those with moderate or severe disease, a bicuspid aortic valve or a prosthetic valve.

Possible complications listed by the NHS include heart failure, atrial fibrillation, stroke and endocarditis, a serious condition where the heart becomes infected. An unexplained fever deserves attention for that reason.

The NHS says to call 999 or go to A&E if you are struggling to breathe, have sudden chest pain that spreads to the arms, back, neck or jaw or lasts more than 15 minutes, or have chest pain with breathlessness or palpitations. Do not drive yourself; ask someone to drive you or call 999, and bring your medicines.

See a GP if you are regularly short of breath, tired, weak or dizzy in normal activities, have palpitations that keep coming back, or swollen ankles and feet, as set out in the symptoms section.

On the NHS, mitral regurgitation is usually found through a GP examination or echocardiogram and managed by a cardiology team, with surgery or transcatheter procedures planned at a specialist valve centre when needed. Some people choose a private cardiology consultation or echocardiogram for quicker access. The tests, guidance and treatment options are the same in principle, and results should be shared with your GP so that monitoring continues.