Valve
Mitral Regurgitation
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Mitral Regurgitation
, Mitral Valve Papillary Muscle Rupture
Precautions
Evaluation and management here focuses on chronic Mitral Regurgitation
Acute Mitral Regurgitation with papillary
Muscle
rupture is also described, but requires emergent management
Pathophysiology
Dysfunction of any of the mitral valve structure may result in Mitral Regurgitation
Mitral valve leaflets
Chordae Tendinae
Papillary
Muscle
s
Mitral annulus
Chronic Early or compensated Mitral Regurgitation
Volume overload
Left Ventricular Hypertrophy
Left atrial enlargement
Chronic Late or decompensated Mitral Regurgitation
Left Ventricular Failure
Decreased ejection fraction
Pulmonary congestion
Acute Mitral Regurgitation due to papillary
Muscle
rupture
Typically affects posteromedial papillary
Muscle
(most tenuous blood supply)
Causes
Acute Mitral Regurgitation (due to papillary
Muscle
rupture)
Common causes of papillary
Muscle
rupture
Acute
Myocardial Infarction
Associated with 50% acute mortality rate
Rare causes of papillary
Muscle
rupture
Infective Endocarditis
Mitral Valve Prolapse
Causes
Chronic Mitral Regurgitation
Rheumatic Heart Disease
(50%)
Mitral Valve Prolapse
Ischemic Heart Disease
and papillary
Muscle
dysfunction
Left Ventricular dilatation
Mitral annular calcification
Hypertrophic Cardiomyopathy
Infective Endocarditis
Congenital Mitral Regurgitation
Symptoms
Dyspnea
Fatigue
Weakness
Cough
Signs
Holosystolic Murmur at Apex
Harsh, medium pitched pansystolic murmur (without respiratory variation)
Murmur obliterates M1
Radiation
Axilla
Upper sternal borders
Subscapular region
Modifiers
Murmur intensity decreases with squatting
Murmur intensity increases with standing
Other heart sounds
Soft or diminished
First Heart Sound
(S1)
P2 heart sound augmented
S2 Heart Sound
with wide split
S3 Gallop
rhythm (indicative of severe disease)
Other findings
Accentuated, hyperdynamic and displaced precordial
Apical Thrust
Systolic thrill
Sharp carotid upstroke (contrast with the delayed and decreased pulsation of
Aortic Stenosis
)
Diagnostics
Electrocardiogram
Left Ventricular Hypertrophy
Left Axis Deviation
Imaging
Chest XRay
Enlarged left atrium
Dilated left ventricle
Echocardiogram
Most important study in the evaluation of Mitral Regurgitation
Test Sensitivity
: 65-85%
Associated Findings
Enlarged left atrium
Hyperdynamic left ventricle
Doppler assesses severity
Monitoring
Annual or semi-annual
Echocardiogram
Assess ejection fraction
Assess end-systolic dimension
Management
SBE Prophylaxis
is no longer recommended
Anticoagulation in Atrial Fibrillation
Treat
Congestive Heart Failure
Diuretic
s
Digoxin
Afterload
reduction
ACE Inhibitor
Hydralazine
Nitroprusside
IV
Milrinone
(also inotropic)
Surgery: Mitral Valve repair or replacement
Repair before
Heart Failure
develops
Keep ejection fraction >60%
Keep end-systolic dimension <45 mm
Indications
Cardiopulmonary Symptoms
Left Ventricular function impaired
References
Kondos (1998) CMEA Medicine Review Lecture, San Diego
Assi (1998) Postgrad Med 104(6):99-110 [PubMed]
Bonow (1998) Circulation 98:1949-84 [PubMed]
Carabello (1997) N Engl J Med 337(1):32-41 [PubMed]
Shipton (2001) Am Fam Physician 63(11):2201-8 [PubMed]
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