Mitral regurgitation

Aetiology *MVP { Myxomatous mv } ,commonest in developed

world* Damage to the cusps :

_ RVD _ IE _ Congenital Cleft MV* Damage to chordae:

_ RVD _ IE _ Trauma _ Degenerative * Damage to papillary muscles :

_ Ischaemia _ Infarction _ Infiltrative _ HCM

* Damage of MV annulus:

_ Calcification _ IE { abscess } * Dilatation of MV ring :

_ IHD _ CMP _ acute RV

Lv volume OL…. LV dilatation maintain normal COP later..…

LV decompensate LVEDP rise LV wall tension increase……

LV fail ….. pulmonary congestion….PH ……CHF

LV dilatation ….dilated MV ring…. > MRBack pressure ….dilated LA …..AF … La thrombus …..

PHP ..

..…CHF …… thrombo-embolic phenomenon

Clinical features:

Symptoms : _ Dyspnoea { pulmonary congestion }

_ Fatigue { low COP } _ Palpitation { AF , increased stroke volume }

_ Oedema , Ascites { RVF } _ Systemic embolization { stroke , ischaemic limb

etc.. }

Signs: _Pulse… Jerky .. AF..

_ Apex … Displaced hyperdynamic _ Apical Pansystolic murmer +/_ Thrill …. 3rd HS

_ Signs of pulmonary congestion …{ crepitations , Pul. Oed. }

_ Signs of PH and RVF .. Loud P2 .. Lt.PS heave … Oedema…

Investigations: * ECG … LAH , LVH ….AF

* Chest X-ray … LA enlargement … Pulmonary congestion..

… LV enlargement …Pulmonary oedema…

* ECHO …. Dilated LA and LV ….Dynamic LV…

.… Structural abnormalities of MV { e.g. MVP }

* Doppler … { CW … PW … color dopler .. } _ Detects and quantifies MR_

* Cardiac catheterization …. Dilated LA and LV …. MR …

..… Assess PH…

..… Detect coexisting CAD …

Chest X-ray PA view

ManagementMedical :

_ For mild and moderate cases

* Diuretic *Vasodilators , e.g. ACEI * Digoxin For AF

*Anticoagulant if AF *Antibiotic Prophylaxis against IE

Surgical :

* MV valvoplasty {Repair }

*MV replacement

Indications:

_ Worsening symptoms _Progressive cardiomegaly _ Deterioration of LV F EF <60% , LVEDD > 55

Indications for Surgery in Isolated ,Severe Chronic Indications for Surgery in Isolated ,Severe Chronic

MRMR **Emerging (minor criteriaEmerging (minor criteria))::

_ _ Any symptoms of heart failureAny symptoms of heart failure _Or sub optimal exercise tolerance test _Or sub optimal exercise tolerance test

_ _ Flail mitral leafletFlail mitral leaflet_ _ Left atrial diameter >45mmLeft atrial diameter >45mm_ _ Paroxysmal atrial fibrillationParoxysmal atrial fibrillation

_ _ Abnormal exercise end-systolic volume indexAbnormal exercise end-systolic volume index

or ejection fractionor ejection fraction

General information

_Most common cause of isolated MR_ Occurs in 5% of adults

_ Most discovered at ages 20- 40_ Affects women > men

_ MV “floppy” or incompetent_ Caused by myxomatous changes

_ May occurs with marfan syndrome_ Cordae may rupture

Clinical features

_ May be asymptomatic _ Mid systolic click +/_ late systolic murmer or PSM

_ MR -- chronic , or acute {rupture CT} _ CHF

_ Increased risk for :

* IE* Arrythmias

* Increased risk of embolic stroke and TIA { small } * Sudden death { rare }

Common Murmurs and Common Murmurs and Timing Timing (click on murmur to (click on murmur to playplay))

Systolic MurmursSystolic MurmursAortic stenosisAortic stenosisMitral insufficiencyMitral insufficiencyMitral valve prolapseMitral valve prolapseTricuspid insufficiencyTricuspid insufficiency Diastolic MurmursDiastolic MurmursAortic insufficiencyAortic insufficiencyMitral stenosisMitral stenosis

S1 S2 S1