Skip to Main Content

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Sudden, severe orthopnea

  • Evidence of pulmonary edema

  • S4

  • Early systolic murmur due to rapid equilibration of left ventricular and left atrial pressures

  • Doppler echocardiography establishes diagnosis, severity, and cause of mitral regurgitation

GENERAL CONSIDERATIONS

  • Disruption of the mitral valve apparatus leading to severe regurgitation is uncommon but often results in profound pulmonary edema

  • Because there is insufficient time for the left ventricle and atrium to dilate, filling pressures rise dramatically back to the lung capillaries

  • Forward stroke volume is markedly reduced because of the large regurgitant volume with a normal left ventricular diastolic volume, resulting in forward heart failure as well

  • If not corrected quickly, acute, severe mitral regurgitation can be rapidly fatal

  • The most common causes of acute, severe mitral regurgitation:

    • – Acute myocardial infarction with papillary muscle rupture or dysfunction

    • – Chordal rupture in mitral valve prolapse

    • – Leaflet disruption due to trauma or endocarditis

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Severe orthopnea, frank pulmonary edema (pink foam in mouth)

  • Symptoms and signs of the causal event may be present, such as acute myocardial infarction, endocarditis, or trauma

PHYSICAL EXAM FINDINGS

  • Low-volume, low-amplitude, and rapid pulse

  • Reduced pulse pressure

  • Low blood pressure may be present later in course

  • Jugular venous distention may be present later in course

  • Increased respiratory rate and diffuse pulmonary rales

  • Pleural effusion may occur later in course

  • Auscultation:

    • – Owing to rapid equilibration of systolic pressure between the left ventricle and atrium, the mitral regurgitant murmur may be short and early systolic, if audible at all

    • – S4 is frequently heard owing to vigorous atrial contraction because of augmented left atrial expansion during systole

    • – P2 may be loud if pulmonary pressures are significantly increased

    • – The murmurs of pulmonic and tricuspid regurgitation may be present with increased pulmonary pressures

DIFFERENTIAL DIAGNOSIS

  • Other causes of acute pulmonary edema not associated with mitral regurgitation

  • Aortic stenosis with heart failure

  • Mitral stenosis with heart failure

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Tests specific to the cause of acute mitral valve disruption, such as blood cultures, may be useful

ELECTROCARDIOGRAPHY

  • Signs of acute myocardial infarction may be present in cases of papillary muscle rupture

IMAGING STUDIES

  • Chest x-ray:

    • – Pulmonary edema without cardiomegaly is classic

    • – Later, other signs of heart failure such as pleural effusions may be seen

    • – Rib fractures may be present if trauma disrupted the mitral valve

  • Echocardiography:

    • – The detection of mitral regurgitation is the most important goal of echocardiography

    • – The color flow jet may not persist throughout systole because of the rapid equilibration between left ventricular and ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.