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Mitral Regurgitation

Title

Ñ    Mitral Regurgitation

Definition

Ñ    Incompetence of the mitral valve with regurgitation

Pathogenesis

Causes

Papillary Muscle

Ñ    Papillary muscle dysfunction

Ñ    Rupture of the papillary muscle:

Myomalacia cordis following myocardial infarction

Chordae Tendinae

Ñ    Rupture of the chordae tendinae:

Infective endocarditis

Mitral valve prolapse

Trauma

Rheumatic mitral valve disease

Valve Leaflets

Ñ    Rheumatic carditis

Ñ    Infective endocarditis

Ñ    Valvotomy

Ñ    Floppy mitral valves

Ñ    Degenerative changes

Ñ    Prosthetic valve dysfunction

Valve Ring

Ñ    Left ventricular dilatation in heart failure

Ñ    Fibrosis

Ñ    Degeneration

Ñ    Paraprosthetic mitral regurgitation

Septum

Ñ    Atrial septal defect:

Ostium primum

Muscle

Ñ    Hypertrophic obstructive cardiomyopathy

Ñ    Endomyocardial fibrosis

Systemic Causes

LMS

Ñ    Marfan’s syndrome

Ñ    Osteogenesis imperfecta

Ñ    Systemic lupus erythematosus

Ñ    Rheumatic fever

IS

Ñ    Ehlers Danlos syndrome

Ñ    Pseudoxanthoma elasticum

Pathophysiology

Ñ    Regurgitation of blood into the left atrium causes left atrial dilatation

Ñ    Left atrial dilatation leads to atrial fibrillation

Ñ    In long-standing disease the pressure does not rise till late in the disease process as the left atrium dilates to accommodate the blood

Ñ    In acute regurgitation the atrium does not have time to dilate

Ñ    Left atrial pressure rises quickly

Ñ    When left atrial pressure increases:

·          Pulmonary venous pressure increases and this results in pulmonary oedema

·          Later pulmonary hypertension occurs

Ñ    As regurgitation of blood from the left ventricle to the left atrium occurs in systole, the stroke volume must increase to maintain cardiac output and hence the left ventricle dilates

Clinical Features

History

Ñ    Symptoms occur late

Ñ    Cardiac dimensions may be greatly increased before any problems occur

E&M

Ñ    Fatigue

Ñ    Lethargy

Ñ    Loss of weight:

Cardiac cachexia

CVS

Ñ    Swelling of the abdomen and ankles:

Right heart failure

RS

Ñ    Dyspnoea

Ñ    Orthopnoea

Examination

E&M

Ñ    Cachexia:

Late stage

CVS

Ñ    Atrial fibrillation

Ñ    Elevated JVP

Ñ    Displaced, thrusting apex

Ñ    Systolic thrill:

Mitral area

Ñ    Left parasternal heave

Ñ    Soft first heart sound

Ñ    Third heart sound

Ñ    Loud P₂ (pulmonary component of the 2^nd heart sound)

Ñ    Short mid-diastolic flow murmur:

Rare

Ñ    Pan systolic murmur radiating to the axilla, back

RS

Ñ    Basal crepitations:

Left ventricular failure

GIT

Ñ    Hepatomegaly:

Congestive cardiac failure

Ñ    Pulsatile liver:

Tricuspid regurgitation

Investigations

Imaging

Chest X-ray 

Ñ    Increased cardio-thoracic ratio

Ñ    LA and LV dilatation

Ñ    Calcification of valves

ECHO

Ñ    Dilated LA (left atrium) and LV (left ventricle)

Ñ    TOE (transoesophageal echocardiogram):

Assessment prior to surgery

Cardiac catheterisation

Ñ    Coexistent coronary artery disease

Ñ    Coexistent aortic valve disease

Ñ    Prior to surgery

Electrophysiology

ECG

Ñ    Bifid P wave

Ñ    LVH and strain

Management

Ñ    Mild disease is managed conservatively by following the patient with serial echocardiograms

Control

Drugs

Ñ    ACE inhibitors

Ñ    Diuretics

Ñ    Digoxin

Ñ    Anticoagulants

Surgery

Ñ    Mitral valve repair or replacement

Indications for surgery

Ñ    Symptomatic patients:

LVEF >30%

ESD < 55mm

Ñ    Symptoms (moderate to severe) despite medical therapy

Ñ    Asymptomatic patients:

·          LV dysfunction:

ESD > 45mm

And/or:

LVEF £ 60%

Prevention

Ñ    Endocarditis prophylaxis

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