Mitral Valve Regurgitation

Overview

What is mitral valve regurgitation?

Mitral valve regurgitation means that one of the valves in your heart-the mitral valve-is letting blood leak backward into the heart.

Heart valves work like one-way gates, helping blood flow in one direction between heart chambers or in and out of the heart. The mitral valve is on the left side of your heart. It lets blood flow from the upper to lower heart chamber.

See a picture of mitral valve regurgitation .

When the mitral valve is damaged-for example, by an infection-it may no longer close tightly. This lets blood leak backward, or regurgitate, into the upper chamber. Your heart has to work harder to pump this extra blood.

Small leaks are usually not a problem. But more severe cases weaken the heart over time and can lead to heart failure.

What causes mitral valve regurgitation?

There are two forms of mitral valve regurgitation: chronic and acute.

• Chronic mitral valve regurgitation, the most common type, develops slowly. Many people with this problem may have a valve that is prone to wear and tear. As the person gets older, the valve gets weak and no longer closes tightly. Other causes include heart failure, rheumatic fever, congenital heart disease, a calcium buildup in the valve, and other heart problems.
• Acute mitral valve regurgitation develops quickly and can be life-threatening. It happens when the valve or nearby tissue ruptures suddenly. Instead of a slow leak, blood builds up quickly in the left side of the heart. Your heart doesn't have time to adjust to this sudden buildup of blood the way it does with the slow buildup of blood in chronic regurgitation. Common causes of acute regurgitation are heart attack and a heart infection called endocarditis.

What are the symptoms?

If you have mild to moderate chronic mitral valve regurgitation, you may never have symptoms. If you have moderate to severe disease, you may not have symptoms for decades.

If your heart weakens because of your mitral valve, you may start to have symptoms of heart failure. Call your doctor if you have any of these symptoms:

• Shortness of breath with activity, which later develops into shortness of breath at rest and at night.
• Extreme tiredness and weakness.
• A buildup of fluid in the legs and feet, called edema.

Acute mitral valve regurgitation is an emergency. Symptoms come on rapidly and include severe shortness of breath at rest, coughing, and fast heartbeat.

How is mitral valve regurgitation diagnosed?

Because you may not have symptoms, a specific type of heart murmur may be the first sign your doctor notices. Further tests will be needed to check your heart. Tests may include:

• Echocardiograms, which use ultrasound to see how serious the valve problem is.
• An electrocardiogram (EKG, ECG) to look for abnormal heart rhythms.
• A chest X-ray to check heart size.
• Cardiac catheterization to see how serious the problem is and to look for coronary artery disease.

Tests for acute regurgitation may include one or more of these same tests, as well as a transesophageal echocardiogram. In this test, a sound-wave device is passed down the esophagus to take clearer pictures of the heart.

Finding out that something is wrong with your heart is scary. You may feel depressed and worried. This is a common reaction. Sometimes it helps to talk to others who have similar problems. Ask your doctor about support groups in your area.

How is it treated?

Treatment for chronic cases includes regularly checking your heart to make sure it is working properly. Treatment also includes preventing infection and treating symptoms as they develop. Your doctor may have you take medicines, including:

• Vasodilators, such as ACE inhibitors, to help widen blood vessels and help the heart work better.
• Diuretics, to treat symptoms of heart failure and reduce the workload on your heart.
• Anticoagulants, such as warfarin (Coumadin), to prevent blood clots if you also have a heart rhythm problem called atrial fibrillation.
• Beta-blockers, antiarrhythmics, or calcium channel blockers, to control heart rate.

You may need surgery to repair or replace your mitral valve if you get symptoms of heart failure, if the size of your left ventricle (your heart's main pumping chamber) increases, or if your heart weakens.

Some doctors believe it's best to repair or replace the valve before you develop severe symptoms because it leads to better long-term health. On the other hand, surgery is a major procedure that has its own risks and complications. Even if you have no symptoms, talk to your doctor about the benefits of surgery, as well as your heart's condition, your age, and your overall health.

Treatment for acute mitral valve regurgitation occurs while you are in the hospital or the emergency room. Because heart failure usually occurs with acute regurgitation, vasodilators are given by IV. You need surgery right away to repair or replace the valve.

If you have chronic mitral valve regurgitation, your doctor may want you to make some lifestyle changes to ease the load on your heart.

• You may need to be careful about physical activity. Talk to your doctor before starting an exercise program.
• If you have a physically demanding job, you may need to change careers.
• You may need to cut down on salt in your diet.

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	Anticoagulants: Vitamin K and your diet

Frequently Asked Questions

Cause

There are two forms of mitral valve regurgitation (MR): chronic and acute. Chronic mitral valve regurgitation develops slowly over several years. Acute MR develops suddenly.

Chronic mitral valve regurgitation

Chronic mitral valve regurgitation is caused by diseases or conditions that damage the mitral valve over time. The valve then allows blood to leak backward (regurgitate).

The mitral valve may become hard, or calcified, around the tough ring of tissue (annulus) to which the mitral valve flaps are attached. Normally the mitral annulus is soft and flexible. But as a person ages, calcium may build up inside the annulus. This hardened mitral valve cannot close completely, and blood leaks backward (regurgitates) into the upper left chamber of the heart (atrium).

Examples of diseases or conditions that can cause mitral valve regurgitation include:

• Mitral valve prolapse.
• Heart defects or abnormalities present at birth (congenital heart defects).
• Endocarditis, which is an infection of the lining of the heart and heart valves. This infection can scar the mitral valve.
• Injury to the heart or the chordae tendineae, which are strong, flexible cords that control the opening and closing of the mitral valve.
• Dilation of the left ventricle, or heart failure. This can be caused by years of high blood pressure, coronary artery disease, or heart muscle disease (cardiomyopathy).
• Autoimmune diseases that can damage the mitral valves, such as rheumatoid arthritis or lupus.
• Marfan's syndrome, which is a connective tissue disease.
• Severe kidney disease.
• Rheumatic fever, which can scar the heart valves and prevent them from closing completely.
• Previous use of the weight-loss medicine fen-phen (phentermine and fenfluramine/dexfenfluramine), which appears to increase the risk of heart valve disease.

Acute mitral valve regurgitation

Acute mitral valve regurgitation occurs when the mitral valve or one of its supporting structures ruptures suddenly, creating an immediate overload of blood volume and pressure in the left side of the heart. Unlike in chronic MR, your heart doesn't have time to adjust to the increased volume and pressure of blood. Causes of the sudden rupture include:

• Injury to the chordae tendineae. This is most common in middle-aged and older men. Endocarditis may also cause the chordae tendineae to rupture.
• Injury to the chest.
• Heart attack, which may cause the rupture of the muscle (papillary) surrounding the valve.
• Problems with a prosthetic mitral valve.
• Perforation of the mitral valve flap (leaflet), caused by endocarditis.

Symptoms

Symptoms of chronic mitral valve regurgitation (MR) may take decades to appear. With acute MR, symptoms come on suddenly and you are critically ill.

Chronic mitral valve regurgitation

If you have mild-to-moderate chronic mitral valve regurgitation, you may never develop symptoms. If you have moderate-to-severe disease, you may not have symptoms for decades. Depending on the severity of your mitral valve regurgitation and condition of your heart, you may not develop symptoms of heart failure for many years.

Symptoms appear as the left ventricle expands to accommodate the larger amount of blood (volume overload) flowing into the chamber. The larger the left ventricle, the more advanced the MR. Symptoms include:

• Shortness of breath with exertion, which may later develop into shortness of breath at rest and at night.
• Fatigue and weakness.
• Fluid buildup in the legs and feet.
• Heart palpitations, if atrial fibrillation develops.

Acute mitral valve regurgitation

Symptoms of acute mitral valve regurgitation develop suddenly. Most people who develop acute MR are already in the hospital or emergency room because of another heart problem. Symptoms include severe shortness of breath, coughing, and rapid or irregular heartbeat.

What Increases Your Risk

Risk factors for mitral valve regurgitation (MR) include:

• Age. Wear and tear of the mitral valve occurs over time, increasing the likelihood of blood leaking back into the atrium.
• Having mitral valve prolapse.
• Having had rheumatic fever, because it can cause scarring on the valve, resulting in incomplete closure.
• Coronary artery disease (CAD). CAD may cause ischemia (reduced blood flow) or infarction (heart attack), which affects the valve's structure, leading to incomplete closure.
• Less commonly, diabetes and Marfan's syndrome because they may lead to hardening of the valve.

When to Call a Doctor

Call 911 or other emergency services immediately if you or a person you are with has:

• Symptoms of a heart attack, including severe chest pain.
• Symptoms of stroke or transient ischemic attack (TIA).
• Loss of consciousness (syncope).
• Difficulty breathing.

Call a doctor immediately if you have:

• Symptoms of heart failure, such as shortness of breath, fatigue, and swelling in the legs and feet.
• Mitral valve regurgitation (MR) and are having symptoms of infection such as fever with no other obvious cause. Be alert for signs of infection if you have recently have had any dental, diagnostic, or surgical procedure.
• Irregular heartbeats.
• Fainting episodes.
• Palpitations.
• Shortness of breath.
• Coughing up blood.
• A decreased ability to exercise at your usual level.
• Excessive fatigue (without other explanation).

Watchful waiting

Watchful waiting is a wait-and-see approach. If you do not have symptoms of MR, your doctor will still want to see you every 6 to 12 months, or as soon as you have symptoms for the first time. If your doctor has talked with you about what to do if you have symptoms, follow your doctor's instructions. Contact your doctor if your symptoms get worse.

Who to see

Health professionals who can evaluate symptoms that may be related to mitral valve regurgitation include:

• Family medicine doctors.
• Internists.
• Nurse practitioners.
• Physician assistants.
• Cardiologists.

They frequently can also order the tests needed for further evaluation of symptoms.

Exams and Tests

Chronic mitral valve regurgitation (MR) can be difficult to diagnose. It is a "quiet" condition and often has no symptoms, or your symptoms may be confused with other heart-related conditions.

Chronic MR is often diagnosed during a routine checkup or a visit to the doctor for another condition. A heart murmur may be the first sign leading your doctor to the diagnosis, especially if you have no other symptoms.

Acute MR causes sudden symptoms and is much less common than chronic mitral valve regurgitation. It is usually diagnosed while you are already hospitalized or in the emergency room.

When your doctor suspects you have MR, he or she will discuss your medical history, do a physical examination, and likely order tests to determine the severity of the regurgitation.

Medical history and physical examination

To determine the severity of your MR, your doctor will ask you to describe any symptoms you are experiencing, such as shortness of breath, fatigue, or chest pain.

During the physical exam, the doctor will take your blood pressure, check your pulse, listen to your heart and lungs, look at the veins in your neck (jugular veins), and check your legs and feet for fluid buildup (edema).

After the medical history and physical examination, your doctor may order a variety of tests, such as an echocardiogram or chest X-ray. Your doctor will want to know:

• The size of your left ventricle as your heart finishes contracting (end systolic dimension, or ESD). In chronic MR, the left ventricle expands as it tries to accommodate the larger amount of blood that flows back into the chamber. The larger the left ventricle, the more advanced the MR. This applies only to the chronic form of the disease because the left ventricle does not expand in acute MR. MR may also develop in response to dilation of the left ventricle that occurs for some other reason.
• Your heart's ejection fraction. This shows the efficiency of your heart. Ejection fraction is the amount (percentage) of blood pumped out of the ventricle compared to the total amount of blood in the left ventricle at rest. The smaller the ejection fraction, the harder your heart must work to pump a sufficient volume of blood.

Echocardiogram

Echocardiogram (sometimes called an echo or echocardiography) is a type of ultrasound examination. It is the best noninvasive method of determining the severity of MR. Also, echocardiography can help determine whether the heart's main pumping chamber (left ventricle) is functioning properly, whether any structural problems exist that may affect the mitral valve, and whether the chambers of the heart are enlarged.

Another form of ultrasound called Doppler echocardiogram (Doppler ultrasound) may be done to evaluate the severity of MR.

If you have severe MR or symptoms, your doctor may recommend an echocardiogram every 6 to 12 months. Your doctor will use the echocardiogram to see if your MR has gotten worse.

Electrocardiogram

An electrocardiogram (EKG, ECG) is a test that measures the electrical signals that control the rhythm of your heartbeat. It may be used to:

• Evaluate abnormal heart rhythms.
• Determine whether there may be enlargement of the heart's chambers.
• Look for signs of a possible previous heart attack.

Although the EKG may reveal abnormal electrical activity in the heart, further testing is often still needed to determine the severity of MR and to confirm whether MR is causing enlargement of the left ventricle. The result of an EKG is often normal in people with mild MR.

Chest X-ray

A chest X-ray may be done to evaluate heart size and to assess symptoms of MR, such as shortness of breath. Calcium deposits on the heart valves may occasionally be seen on a chest X-ray.

Cardiac catheterization

Cardiac catheterization (also called coronary angiogram), a test that evaluates your heart and heart (coronary) arteries, may be done to:

• Confirm the severity of mitral valve leakage seen on an echocardiogram.
• Check for coronary artery disease before valve repair or replacement surgery. If severe blockage is seen in the coronary arteries, the blockage may be corrected during the same open-heart surgery to correct the damaged valve.

Tests for acute mitral valve regurgitation may include one or more of the tests used for chronic MR as well as a transesophageal echocardiogram. In this test, a device that sends sound waves is passed down the esophagus to take clearer pictures of the heart.

Treatment Overview

Treatment for chronic mitral valve regurgitation (MR) includes monitoring your heart function and symptoms, as well as treating symptoms as they develop. If MR becomes severe, the mitral valve will need to be repaired or replaced. Treatment for acute MR is immediate. Medicines and urgent surgery are usually necessary.

As you review your treatment options, consider the following:

• If you have mild-to-moderate chronic MR and no symptoms, your doctor may only monitor your condition.
• If you have moderate-to-severe MR but no symptoms, your doctor may suggest repair or replacement of the mitral valve before symptoms develop, to prevent further heart damage.
• If you have chronic MR, medicines may be used to treat your symptoms and prevent complications. For acute MR, medicines are used to stabilize your condition, but urgent surgery is usually necessary.
• Severe MR generally requires valve repair or replacement to prevent heart failure. Repairing a damaged valve is preferred over replacement.

Initial treatment

Initial treatment for chronic mitral valve regurgitation depends on whether you have symptoms and how severe the regurgitation is. If you don't have symptoms and you only have mild-to-moderate regurgitation, your doctor may only monitor your heart and valve function with an echocardiogram.

The echocardiogram uses painless ultrasound waves to check how well your heart is pumping blood (ejection fraction) and to measure the size of your left ventricle. The smaller the ejection fraction, the harder your heart must work to pump a sufficient volume of blood.

Surgery is recommended when ejection fraction drops below 60% and/or your left ventricle is larger than 40 mm at rest.¹ If you need surgery, your doctor may suggest repairing or replacing your mitral valve to avoid further heart damage. When you begin to have symptoms, the regurgitation is advanced, and you will need surgery to prevent heart failure.

Your doctor may prescribe medicines, such as:

• Vasodilators, such as ACE inhibitors, to help widen blood vessels and help the heart pump more efficiently, if you have symptoms of MR.
• Anticoagulants, such as warfarin (Coumadin), to prevent blood clots if you also have atrial fibrillation.
• Other medicines to control heart rate if you have atrial fibrillation, including beta-blockers, digoxin, or calcium channel blockers.
• Diuretics, for symptoms of heart failure and to reduce the workload on your heart.

Initial treatment for acuteMR includes use of the above medicines as necessary to stabilize your condition. If medicines don't help, an intra-aortic balloon pump may be necessary. This device has a balloon attached to the end of a catheter and is threaded up into the aorta, the main artery leaving the heart. The balloon inflates and deflates in sequence with your heartbeat to help circulate blood, decrease the heart's workload, and increase blood flow. Urgent surgery to repair or replace your mitral valve will also be necessary, as well as treatment for the cause of the acute MR.

Ongoing treatment

Like initial care for chronic mitral valve regurgitation (MR), ongoing treatment with medicines or surgery varies according to the progression of the disease.

Your doctor may prescribe medicines to help control high blood pressure.

You will need periodic echocardiograms to see if regurgitation is getting worse, and to check the size of your left ventricle and how well it is working. In chronic MR, the left ventricle expands in size as it tries to accommodate the larger volume of blood going into the chamber. The larger the left ventricle, the more advanced the MR.

Your doctor will also monitor your heart's ejection fraction, which is a measure of how well your heart is pumping blood. Ejection fraction is the amount of blood pumped out of the ventricle (stroke volume) divided by the total amount of blood in the left ventricle at rest. The smaller the ejection fraction, the harder your heart must work to pump a sufficient volume of blood.

Surgery is recommended when ejection fraction drops below 60% and/or your left ventricle is larger than 40 mm at rest.¹ If you need surgery, your doctor may suggest repairing or replacing your mitral valve to avoid further heart damage. When you begin to have symptoms, the regurgitation is advanced, and you will need surgery to prevent heart failure.

Treatment if the condition gets worse

If your mitral valve regurgitation becomes severe and you develop symptoms of heart failure, such as shortness of breath, swelling, and fatigue, surgery to repair or replace your mitral valve will be necessary. Surgery is also recommended when your ejection fraction drops below 60% and/or your left ventricle is larger than 40 mm at rest.¹

Some doctors believe it's best to repair or replace the mitral valve before you develop severe symptoms because it leads to better long-term health. On the other hand, surgery to correct MR is a major procedure that has its own risks and complications. Even if you have no symptoms, talk to your doctor about the benefits of surgery, along with your heart's condition, your age, and your overall health.

The decision between repairing or replacing the valve depends on the type of damage to the mitral valve. For instance, repair is more successful if there is limited damage to certain areas of the mitral valve flaps (leaflets) or to the chordae tendineae, the tough fibers that control movement of the mitral valve leaflets. But replacement is usually preferred for people who have a hard, calcified mitral valve ring (annulus) or widespread damage to the valve and surrounding tissue.

Repair may be done by reshaping the valve or removing excess tissue, adding support to the valve ring, or attaching the valve to other cordlike tissues in the heart (chordal transposition).

With replacement, the badly damaged valve is removed, and a mechanical (plastic or metal) or a bioprosthetic valve (usually made from pig tissue) is sewn into place. If you receive a mechanical valve, you are more likely to develop blood clots in the heart than if you receive a bioprosthetic valve, so you will need anticoagulant medicine for the rest of your life to prevent clots from forming and possibly causing a stroke.

Ongoing Concerns

Chronic mitral valve regurgitation (MR) develops slowly, and most people go years without having any symptoms. Before symptoms start, your condition may not be serious and you generally feel good. But even during this time, MR is doing irreversible damage to your heart. Because of this ongoing damage, your doctor may suggest surgery before you start having symptoms. Although it may be difficult to think about surgery when you feel well, not having surgery could lead to heart failure.

You will begin to have symptoms of chronic MR when your heart begins to weaken. A variety of medicines are available to treat your symptoms as MR progresses and to prevent complications.

Complications

People with mitral valve regurgitation sometimes develop serious complications including:

• Heart failure.
• Endocarditis.
• Irregular heartbeats (arrhythmias).

Living With Mitral Valve Regurgitation

After you are diagnosed with mitral valve regurgitation (MR), it is important to watch for symptoms of heart failure. These symptoms indicate that your heart is weakening and MR is getting worse. Symptoms of heart failure include shortness of breath, fatigue, and swelling in your feet and ankles. If new symptoms develop or preexisting symptoms become worse, call your doctor.

You may need to be cautious about physical activity if you have symptoms, irregular heart rhythms, or changes in your heart size or function. But regular activity, even low-level activity such as walking, will help keep your heart healthy. If you want to start being more active, talk to your doctor first. Your doctor will help you create a safe exercise plan.

Your doctor may advise you to limit sodium in your diet. If you consume too much salt, it will cause your body to retain excess fluid. Most of the sodium in our diets comes from processed foods, not the salt shaker. Foods to avoid include potato chips, pretzels, salted nuts, processed meats and cheeses, pizza, canned soups, canned vegetables, olives, fast foods, and frozen dinners (unless the label clearly states the product is low-sodium).

When you are grocery shopping, check labels carefully for sodium content. Your doctor may advise you to limit salt to less than 2,300 mg a day. Add more fresh fruit and vegetables to your diet to replace foods high in sodium. Read labels carefully to identify sources of hidden sodium in your diet.

If you have an artificial valve, you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis.

Medications

Medicines do not prevent or correct the damage to the heart caused by mitral valve regurgitation (MR). But in chronic MR, medicines may help relieve symptoms in people who are not good candidates for surgery or in people who are waiting for surgery to repair or replace their damaged valve.

People with chronic and severe MR who also have an enlarged, abnormally functioning left ventricle may not benefit from mitral valve surgery and are often treated with medicines to relieve their symptoms. Depending on the severity of their MR, some older people may also be treated with medicines because they may be at greater risk for developing complications during or following surgery. A number of medicines are used to treat MR.

• Vasodilators (such as ACE inhibitors) widen blood vessels and may be used to help the heart pump more efficiently and to reduce regurgitation.
• Anticoagulants prevent blood clots and may be used after valve surgery or when atrial fibrillation is present.
• Aspirin prevents blood clots and may be used after mitral valve surgery or as a preventive step.
• Beta-blockers, antiarrhythmics, or calcium channel blockers may be used if atrial fibrillation is present.
• Digoxin may be used if atrial fibrillation or the symptoms of heart failure are present.
• Diuretics are useful if heart failure is present.
• Antibiotics may be used to lower the risk of rheumatic fever. Or they may be used if you have an artificial heart valve to lower the risk of a heart infection (endocarditis).

In acute MR, medicines are used to stabilize your condition until you can have surgery to replace or repair the valve. Vasodilators such as nitroprusside help reduce the amount of blood flowing back into the left atrium. Diuretics help reduce workload on the heart.

What to think about

If you take warfarin, don't suddenly change your intake of foods that are rich in vitamin K. Vitamin K can interfere with the action of anticoagulants, making it more likely that your blood will clot. For more information, see:

Anticoagulants: Vitamin K and your diet.

Surgery

If your chronic mitral valve regurgitation (MR) becomes severe or you develop symptoms of heart failure, such as shortness of breath, swelling, and fatigue, surgery to repair or replace your mitral valve will be necessary. Regardless of symptoms, surgery is recommended when your ejection fraction drops below 60% and/or your left ventricle is larger than 40 mm at rest.¹

Having surgery on your valve before symptoms occur may help you avoid heart damage that is beyond repair. Some doctors believe it's best to repair or replace the valve before you develop severe symptoms because people who have severe symptoms don't recover as well as people who do not.

The decision between repairing or replacing the valve depends on the type of damage you have. For instance, repair is more successful if there is limited damage to certain areas of the mitral valve flaps (leaflets) or to the chordae tendineae, the tough fibers that control movement of the mitral valve leaflets. But replacement is usually preferred for people who have a hard, calcified mitral valve ring (annulus) or widespread damage to the valve and surrounding tissue.

Repair is preferred over replacement because research shows that:²

• Repair leads to better long-term survival.
• Long-term anticoagulants are not needed after repair.
• There is better function of the left ventricle following repair.
• There is less risk of serious bleeding after repair.

Repair may be done by reshaping the valve or removing excess tissue, adding support to the valve ring, or attaching the valve to other cordlike tissues in the heart (chordal transposition).

With replacement, the badly damaged valve is removed and a mechanical (plastic or metal) or bioprosthetic valve (usually made from pig tissue) is sewn into place. If you receive a mechanical valve, you are more likely to develop blood clots in the heart than if you received a bioprosthetic valve, so you will need anticoagulant medicine for the rest of your life to prevent clots from forming and possibly causing a stroke.

Surgery is usually delayed if no symptoms or signs of heart failure are present. People with severe MR, no physical symptoms, and whose left ventricle is functioning normally may be monitored every 6 to 12 months by their doctor. If follow-up testing shows enlargement or abnormal function of the left ventricle, surgery is then usually advised.

With acute MR, urgent surgery to repair or replace the valve is usually necessary. In some cases, surgery to correct the cause of acute MR may also be needed.

Other Places To Get Help

Organizations

Related Information

• Atrial Fibrillation
• Care at the End of Life
• Coronary Artery Disease
• Endocarditis
• Heart Attack and Unstable Angina
• Heart Failure
• Mitral Valve Prolapse
• Mitral Valve Stenosis

References

Citations

1. Bonow RO, et al. (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). Circulation, 114(5): e84-e231.

2. Curtin RJ, Griffin BP (2006). Valvular heart disease. In DC Dale, DD Federman, eds., ACP Medicine, section 1, chap. 11. New York: WebMD.

Other Works Consulted

• Bonow RO, et al. (2005). Task Force 3: Valvular heart disease. Journal of the American College of Cardiology, 45 (8): 1334-1340.

• Hirsch J, et al. (2008). Executive summary: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed.). Chest, 133(6): 71-109.

• Nishimura RA, et al. (2008) ACC/AHA 2008 guideline update on valvular heart disease: Focused update on infective endocarditis: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation, 118(8): 887-896.

• Otto CM, Bonow RO (2008). Valvular heart disease. In P Libby et al,. eds., Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed., pp. 1625-1692. Philadelphia: Saunders Elsevier.

• Rodriguez L, Gillinov AM (2007). Mitral valve disease. In EJ Topol, ed., Textbook of Cardiovascular Medicine. Philadelphia: Lippincott Williams and Wilkins.

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