Mitral Regurgitation

Question 1

How may MR present?

Answer 1

Heart failure
AF

Question 2

Causes of mitral regurgitation

Answer 2

Degenerative (calcification)
Functional (due to LV dilation)
Ischaemia and chorea rupture
IE
Rhematic fever

Mitral valve prolapse (common in young tall women):
- Marfans
- EDS
- Myxomatous degeneration
- ADPKD

Question 3

Clinical signs of MR (not auscultation)

Answer 3

AF
Raised JVP (if HF)
Sternotomy
Mini Rt thoracotomy (minimally invasive MR replacement if coronary arteries okay)
loud P2 (if pul htn)
Parasternal heave (if pul HTN)
Displaced thrusting apex beat (may have thrill)
signs of endocarditis

Other features of aetiology i.e. marfarnoid/ EDS

Question 4

Auscultation of MR

Answer 4

Quiet S2.
S3/S4
Pansystolic murmur radiate to axilla loud on expiration
Widely split S2 (severe MR)

Question 5

Causes of MV prolapse

Answer 5

primary myxomatous disease
HOCM
ADPKD
Marfans
CTD

Question 6

Auscultation of MVP

Answer 6

midsystolic systolic murmur with ejection click louder up to A2

Question 7

What increases MVP sounds

Answer 7

Anything that makes heart smaller (i.e. standing) will make murmur louder)
Anything that makes heart larger (i.e squatting) (increases venous return+increases afterload) makes murmur quieter.

Question 8

Complications of MVP

Answer 8

Thromboemboli/ IE/ CVD/ sudden cardiac death

Question 9

How is severity of MR graded clinically

Answer 9

Mild: SR + no heart failure
Moderate: no features of severe
Severe: pulmonary HTN + AF + heart failure

Question 10

Investigations of MR

Answer 10

ECG (P-mitrale/ AF
XR chest
TTE
TOE
Heart catheterisation

Others
Carotid duplex USS
OPG (?dental extraction prior to repair)

Question 11

Why conduct a TTE

Answer 11

Assess severity and causes (prolapse/ vegetation/infarction)

Question 12

Why is a TOE preferred preoperatively?

Answer 12

Allows assessment of valve for surgical repair

Question 13

Why conduct cardiac catherisation?

Answer 13

Assess coronary arteries prior to repair and pulmonary pressures
?CABG simultaneously

Question 14

When is surgical management indicated?

Answer 14

Asymptomatic with EF <60% + LV dimension >40mm
Severe in presence of AF/ pulmonary HTN
Dilated/ impaired LV <30% EF

Question 15

Medical management of MR

Answer 15

Anticoagulation (AF)
Management of HF (beta blockers/ ACEI/ diuretic)

Question 16

Why is repair preferred to replacement

Answer 16

Disconnection of the subvalvular apparatus can result in up to 20 % decline in LV function so MV replacement without chordal preservation should be avoided when possible

Question 17

What surgical procedures can be offered

Answer 17

MV repair
MV replacement
MV Clip (percutaneous palliative procedure in patients unfit for surgery)

Question 18

Should ischaemic MR be managed differently to other causes of MR?

Answer 18

Yes, there should be a lower threshold to treat as definitions of severe MR are lower in this cohort.