mitral regurgitation(mitral insufficiency, mitral incompetence)

8/7/2019 Mitral Regurgitation(Mitral Insufficiency, Mitral Incompetence)

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Mitral regurgitation(mitral

insufficiency, mitral incompetence)

mitral valve doesnot close properly when theheart pumps the blood

Abnormal leaking of blood from left ventriclethrough mitral valve into the left atrium.


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Anatomy

2 valve leaflets

Annulus

Papillary musclesChordae tendinae


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Pathology

Any dysfunction of above structure leads to

mitral regurgitation.


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Etiology

1. Mitral valve prolapse

2. Ischaemic heart diseases

3. Rheumatic fever4. Marfans syndrome

5. Secondary mitral regurgitation

Eg, aortic insufficiency


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Acute mitral regurgitation

1. Endocarditis

2. Papillary muscle rupture

3. Mvp4. Chest trauma

5. Cardiac surgery


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Pathophysiology

1. Acute phase

2. Chronic compensated phase

3. Chronic decompensated phase


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Acute phase

Sudden rupture of chordae tendinae or

papillary muscles

Volume overload of left ventricle and leftatrium


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Acute phase

Volume overload of left ventricle

Forward stroke+regurgitant volume

Starlings law More SV

Later LV volume

Loss Contractility

dysfunction


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Continued acute phase

Regurgitant volume in LA

Volume + pressure

Pulmonary conges.


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Chronic compensated phase

If mitral regurgitation develops slowly over

months and years

Or if can be managed medically

Hypertrophy Diastolic vol.Strokevolume


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Chronic compensated phase

Vol overload

Enlargement of LA

Filling pressureDrainage from pulmonary veins

Congestion

So asymptomatic,May be normal exercise tolerance.


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Chronic decompensated

Eventually LV may be dysfunctional by not

contracting.


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Chronic decompensated

Sv

Co

E

ndsystolic volFilling pressure

Pulmonary congestion

Dilatation

Mitral valve annulus dilatation

Mitral regurgitation


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Symptoms

Acute

Chf

i. Shortness of breathii. Pulmonary oedema

iii. Orthopnea

iv. Paroxysmal nocturnal dyspnoea

v. Fatiguability

vi. Decreased exercise tolerance


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Symptoms

Chronic compensated

i. Asymptomatic

ii. Normal exercise toleranceiii. No evidence of heart failure

iv. But sensitive to vascular volume shifts


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Signs

Pulse

-High volume,collapsing in severe

-Irregular rhythm in atrial fibrillation Jugular veins

-Disappearance of a wave in atrial fibrillation

- Prominent a wave in pulmonary hypertension


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signs

Blood pressure

Wide pulse pressure in severe mitral

regurgitation


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Inspection

Apex beat shifted laterally and downward

Systolic thrill at apex

Sustained left parasternal heave and palpablepulmonary component of second heart sound

in pulmonary hypertension


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Auscultation

First heart sound usually soft

Severe mitral stenosis, S2 widely split due to

arotic vavle closure occuring early Pulmonary component of P2 is loud in

pulmonary hypertension

Pulmonary ejection sound in pulmonaryhypertension


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murmur

Pansystolic murmur heard best at apex

radiating to the axilla and left interscapular

area

Other murmur

- ejection systolic murmur in pulmonary

hypertension

-pansystolic murmur at left sternal border due

to functional tricuspid regurgitation


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Investigations

Ecg

-left atrial enlargement

-Left ventricular dilatationa and hypertrophy-atrial fibrillation

Echocardiogram

-enlarged left atrium

_hyperdynamic left ventricle


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investigations

Chest radiography

-cardiomegaly with left atrial and left ventricular

enlargement-calcification of mitral valve


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management

1. Atrial fibrillation

2. Heart failure

3. Restriction of physical activity4. Treatment based on etiology


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Surgical management

Mitral valvuloplasty

Mitral valve replacementS

mitral regurgitation(mitral insufficiency, mitral incompetence)

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