Mitral Regurgitation

Question 1

Causes of mitral regurgitation. (MR)

Answer 1

Degenerative myxomatous disease

IHD

Rheumatic heart disease

Infectious endocarditis

SLE

Cardiomyopathies like dilated and hypertrophic cardiomyopathy.

Collagen diseases like Marfan’s and EDS.

Pectus excavatum

Drugs

Dilated annulus from LV dilation

Ruptured chordae, pappilary muscles.

Question 2

Epidemiology of MR.

Answer 2

Remain asymptomatic for many years.

From diagnosis to onset of symptoms is 16 years.

Most patients with chronic MR have mild-moderate disease and are unlikely to ever need surgical intervention.

Question 3

Symptoms of MR.

Answer 3

SOB

Fatigue

Palpitations

Symptoms of causative factor

Orthopnoea

Symptoms of RHF and LHF.

Cardiac cachexia

Question 4

Murmur of MR

Answer 4

Pan-systolic, high pitched “whistling” murmur due to high velocity blood flow through the leaky valve.

The murmur radiates to left axilla. You may hear a third heart sound.

Soft S1

Split S2

Question 5

Signs of MR.

Answer 5

AF

Lateral displaced hyperdynamic apex beat

Pansystolic murmur at apex radiating to axilla. This is best heard over 5th ICS mid clavicular line.

Soft S1

Split S2

Loud P2 (pulm HTN)

Question 6

Investigations of MR.

Answer 6

ECG

CXR

Echocardiogram (diagnostic)

Cardiac catherisation (used to confirm diagnosis as well)

Question 7

ECG findings in MR.

Answer 7

P-mitrale if in sinus rhythm (bifid P waves)

LV hypertrophy by tall R waves in left lateral leads like I and V6

Deep S waves in V1 and V2.

AF may be present.

Question 8

CXR findings in MR.

Answer 8

Big left atrium and left ventricle

Mitral valve calcification

Pulmonary oedema

Increased cardiothoracic ratio

Question 9

Echocardiogram in MR.

Answer 9

Assess LV function and MR severity and aetiology.

It will show a dilated left atrium and left ventricle.

Question 10

Progression of disease in MR.

Answer 10

Regurg leads to left atrial dilation.

This leads to pulmonary oedema due to pulmonary HTN and an increase in stroke volume leading to LV hypertrophy.

Question 11

Management of MR.

Answer 11

Control rate with b-blockers/ rate-limiting CCBs as well as warfarin if AF.

Anticoagulate if histoy of embolism, prosthetic valve or additional mitral stenosis.

Diuretics to improve symptoms

Surgery if indicated.

Question 12

Surgical options in MR.

Answer 12

Mitral valve replacement

Mitral valve repair

Repair has advantages such as lower mortality (1-2% vs 5-10%)

Question 13

Indications for surgical intervention in MR.

Answer 13

Severe MR

Symptomatic patients

Asymptomatic patients with mild-moderate LV dysfunction (EF 30-60% and LVESD 4.5 - 5.5 cm)

Question 14

When are ACEi used in MR?

Answer 14

If there is functional or ischaemic MR.

If there is LV systolic dysfunciton present ACEi and B-blockers and CRT have all been shown to reduce the severity of MR.

Question 15

What renal disease is mitral valve prolapse associated with?

Answer 15

APCKD

Question 16

Surgery in MR

Answer 16

Mitral valve repair (used if anatomy of the valve is suitable as it has many advantages including mortality rates to replacement)

or

Mitral valve replacement

Question 17

Indications of surgery

Answer 17

Symptomatic MR

Asymptomatic patients with mild-moderat LV dysfunction