Mitral Incompetence

Question 1

Clinical signs (pulse, apex, thrill/heave, ascultation)

Answer 1

Small volume pulse, AF
Displaced apex
Thrill at apex
Split A2P2 as LV empties quickly
Pan-systolic murmur loudest at apex during expiration
S3

Question 2

Causes

Answer 2

Congenital
Acquired: endocarditis, degeneration leading to prolapse, rheumatic, CTD, fibrosis (pergolide/trauma), functional MR from dilated LV, calcification, amyloid

Question 3

How would you investigate this patient?

Answer 3

Bedside: ECG (p-mitral, AF, Q waves if previous infarct)
Bloods
Imaging: CXR, TTE/TOE

Question 4

How would you manage this patient?

Answer 4

Medical: anticoag for AF; diuretics, B-blocker, ACEi
Surgical: percutaneous mitral clip, valve repair with annulopasty ring or replacement

Question 5

Prognosis if symptomatic

Answer 5

25% at 5 years

Question 6

Chronic Mitral Regurge
Indications for surgery

Answer 6

1. Chronic, Symptomatic and Severe with EF >30%
2. Chronic, Symptomatic and EF <30% or LVESD >55mm but low comorbidity and MR is refractory to medical therapy
3. Asymptomatic and LV dysfunction
4. Asymptomatic with preserved LV function AND new AF or pulmonary hypertension
5. Asymptomatic with preserved LV function AND a flail leaflet or atrial dilatation in SR if durable repair likely and surgical risk low