Care New England Advanced Valvular and Structural
Heart Disease Clinic

Mitral regurgitation, or leaky valves, is a common valvular disorder that can arise from abnormalities of any part of the mitral valve structure. These include the valve leaflets, annulus, chordae tendineae, and papillary muscles.

There are two forms:

• Primary – causes include degenerative mitral valve prolapse, rheumatic heart disease, infective endocarditis, trauma, certain drugs, cleft mitral valve, and mitral annular calcification
• Secondary – causes include coronary heart disease and cardiomyopathies (eg, dilated or hypertrophic cardiomyopathy). Ischemic MR primarily occurs in patients with a prior myocardial infarction. 

Many patients are asymptomatic, but symptoms may include dyspnea on exertion and fatigue, and atrial fibrillation, or a brisk arterial pulse in someone with chronic mitral regurgitation.

Echocardiograms are primarily used to diagnose, and criteria to determine severe mitral regurgitation is a vena contracta width of greater than 0.7 centimeters, a regurgitant fraction of greater than 50 percent, and a regurgitant jet area of greater than 40 percent of the left arterial region.

Multiple valvular, vascular, and ventricular maladies have interactions with one another where physical impacts associated with each amplify the effects on the cardiovascular system.

Care New England was awarded a Centers for Medicare and Medicaid Innovation Grant to develop a system-wide infrastructure that allows for improved communication and technology use between providers related to the care of patients with congestive heart failure. The goal of the program is to reduce hospital readmissions for congestive heart failure.

Atrial septal defects are the most common congenital heart lesion in adults and are often asymptomatic until adulthood. They are associated with shunts, or holes, that cause a volume overload of the right heart chambers.

Most patients with an atrial septal defect and significant shunt flow will have symptoms such as atrial arrhythmias, exercise intolerance, fatigue, dyspnea, and heart failure and require the closure of the shunt. The evaluation of the shunt relies extensively on the size, location, and direction, and can be diagnosed using an echocardiogram.

Patent foramen ovale is a very common congenital cardiac lesion that can persist through someone’s lifetime. They can also be associated with cryptogenic strokes. The prevalence of the condition decreases with age, but the size of the lesion increases over time, however.

Rarely are there signs of the condition, but testing may need to be performed after certain medical events, including cerebral ischemia or air embolism.

An echocardiogram can diagnose the condition, along with an agitated saline contrast, which is when the saline solution is administered intravenously to provide an air microbubble contrast in the right part of the heart.

Ventricular septal defects are one of the most common congenital heart defects but account for only 10 percent of congenital heart defects in adults because many close spontaneously over time. They vary in size, location, and number. They can occur as isolated defects or they can be part of complex congenital heart defects. 

Most small ventricular septal defects close during childhood and most rarely require any intervention, although there is a very low risk of complications such as double-chambered right ventricle and sinus of Valsalva dilatation or aneurysm. Those with a persistent septal defect are in danger of developing pulmonary hypertension and endocarditis.

Some patients who have a worsening prognosis may require a surgical procedure such as aortic valve surgery.

Hypertrophic cardiomyopathy is a genetically determined heart muscle disease most often caused by mutations in one of several genes which encode parts of the mechanical system of the heart.

It manifests as left ventricular hypertrophy and can develop into one of the following abnormalities:

• Left ventricular outflow obstruction
• Diastolic dysfunction
• Myocardial ischemia
• Mitral regurgitation

Symptoms include:

• Fatigue
• Dyspnea
• Chest pain
• Palpitations
• Presyncope or syncope

This condition can lead to heart failure and stroke. There may be a family history as well, and an echocardiogram is used to diagnose hypertrophic cardiomyopathy. Stress testing may also be used, and genetic testing is also available.