Updated: 2/10/2020

Mitral Regurgitation

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Snapshot
  • A 56-year-old man presents to his cardiologist for dyspnea. He previously had dyspnea with exertion. In the past few weeks, he has had dyspnea at rest as well. He also reports easy fatigability. He has a previous history of hypertension and ischemic heart disease. He currently takes statins, metoprolol, captopril, and furosemide. On physical exam, there is a holosystolic murmur heard best at the apex, a systolic thrill, and S3 heart sound. An echocardiogram reveals left ventricular hypertrophy, left atrial enlargement, and mitral regurgitation.
Introduction
  • Clinical definition
    • a valvular disorder characterized by mitral valve insufficiency
      • acute or chronic
  • Epidemiology
    • demographics
      • male > female
    • risk factors
      • coronary artery disease
      • past myocardial infarction
  • Etiology
    • acute
      • rupture of chordae tendinae
      • papillary muscle rupture
      • infective endocarditis
      • trauma
    • chronic
      • rheumatic heart disease (most common in developing countries)
      • mitral valve prolapse (most common in developed countries) 
      • infective endocarditis
      • hypertension
      • ischemic heart disease
      • hypertrophic obstructive cardiomyopathy
      • congenital
  • Pathogenesis
    • mitral insufficiency results in blood flow from the left ventricles to the left atrium (LA) instead of into systemic circulation
      • ↑ LA pressure
      • ↑ volume overload and preload
      • ↓ cardiac output
        • as left ventricle empties some of its blood into the low-pressure compartment of LA
      • over time, this results in left ventricular failure
  • Associated conditions
    • tuberous sclerosis
Presentation
  • Symptoms
    • heart failure
      • dyspnea
      • orthopnea
      • paroxysmal nocturnal dyspnea
      • fatigue
  • Physical exam
    • cardiac exam
      • downward-displaced left ventricular impulse
      • holosystolic apical murmur
        • radiates to axilla
        • best heart at apex
      • systolic thrill
      • S3 heart sound
    • pulmonary rales
    • peripheral edema
Imaging
  • Chest radiography
    • indication
      • initial imaging
    • findings
      • increased pulmonary vasculature
      • cardiomegaly
      • left atrial enlargement
  • Echocardiography
    • indication
      • diagnostic test
    • findings
      • mitral insufficiency
      • left heart enlargement
Studies
  • Electrocardiogram
    • findings
      • left ventricular hypertrophy
      • left atrial enlargement
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Ventricular septal defect (VSD)
    • distinguishing factors
      • also presents with holosystolic murmur
      • may be asymptomatic or may develop heart failure
      • no S3 sound or thrill
      • echo shows VSD
Treatment
  • Management approach
    • treat heart failure if present
  • Medical
    • vasodilating drugs
      • indication
        • for all patients
      • drugs
        • angiotensin receptor blockers
        • angiotensin-converting enzyme inhibitors
        • hydralazine
    • diuretics
      • indication
        • for patients with heart failure
    • β-blockers
      • indication
        • for patients with heart failure
  • Operative
    • valvular repair or replacement
      • indications
        • ejection fraction ≤ 60%
        • left ventricular end systolic diameter ≥ 40 mm
        • refractory to medical therapy
Complications
  • Heart failure
  • Cardiogenic shock
  • Pulmonary hypertension
  • Atrial fibrillation

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