FN: Mitral Regurgitation

Question 1

Causes

Answer 1

1. Mitral valve prolapse
2. LV dilatation: AR, AS, HTN
3. Annular calcification - contraction (elderly)
4. Post-MI: papillary muscle dysfunction/rupture
5. Rheumatic fever
6. Connective tissue: Marfans, ehlers-danlos

Question 2

Symptoms

Answer 2

Dyspnoea, faitgue
AF - palpitations + emboli
Pulmonary congestion - HTN + oedema

Question 3

Signs

Answer 3

AF
Left parasternal heave (RVH)
Apex: displaced
Heart sounds
Murmur

Question 4

Apex

Answer 4

Displaced

Volume overload as ventricle has to pump forward SV and regurgitant volume - eccentric hypertrophy

Question 5

Heart sounds

Answer 5

Soft S1
S2 not heard separately from murmur
Loud P2 (if PTH)

Question 6

Murmur

Answer 6

blowing PSM
Apex
Left lateral position in end expiration
Radiates to the axilla

Question 7

Clinical indication of Severe MR

Answer 7

Larger LV
Decompensation: LVF
AF

Question 8

Differential

Answer 8

AS
TR
VSD

Question 9

Investigations

Answer 9

bloods
ECG
CXR
Echo
Cardiac catheterisation

Question 10

Bloods

Answer 10

FBC
U+E
Glucose
Lipids

Question 11

ECG

Answer 11

AF
P mitrale (unless in AF)
LVH

Question 12

CXR

Answer 12

LA and LV hypertrophy
Mitral valve calcification
Pulmonary oedema

Question 13

Echo

Answer 13

Doppler echo to assess MR severity: multiple ccriteria

1. Jet width (vena contracts) >0.6cm
2. Systolic pulmonary flow reversal
3. Regurgitant volume >60ml

TOE to assess severity and suitability of repair cf. replacement

Question 14

Cardiac catherisation

Answer 14

Confirm Dx

Assess CAD

Question 15

Management medical

Answer 15

Optimise RFs: statins, anti-hypertensives, DM
Monitor: regular f/up with echo
AF: rate control and anticoagulate - also anticoagulate if hx of embolism, prosthetic valve, additional MS

Drugs to reduced afterload can help reduce symptoms
1. ACEi or beta-blockers (esp. carvediol)
Diuretics

Question 16

Surgical management

Answer 16

Valve replacement or repair
Indications:
1. Severe symptomatic MR
Severe asympto MR with diastolic dysfunction: reduced EF