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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Disease principally of the mitral valve leaflets caused by myxomatous changes, rheumatic fever, collagen vascular disease, or endocarditis

  • Dyspnea or orthopnea

  • Characteristic apical systolic murmur

  • Doppler echocardiographic evidence of systolic regurgitation into the left atrium

GENERAL CONSIDERATIONS

  • Mitral regurgitation refers to systolic leakage of blood from the left ventricle to the left atrium

  • Organic mitral regurgitation refers to diseases that involve the leaflets or their immediate supporting apparatus: chordae and the mitral annulus

  • Among causes of organic mitral regurgitation, mitral valve prolapse is a unique entity (covered separately)

  • Causes of chronic organic mitral regurgitation:

    • – Rheumatic heart disease

    • – Infective endocarditis

    • – Collagen vascular diseases

    • – Trauma

  • Mitral regurgitation of any etiology tends to worsen over time because the volume load on the left heart results in chamber dilation, which further compromises mitral competence

  • Although slowly progressive, mitral regurgitation may ultimately result in a large dysfunctional left ventricle and left atrium

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • History of potential causal factors such as rheumatic fever and collagen vascular disease

  • Progressive dyspnea

  • Fatigue, orthopnea with heart failure

  • Palpitation, usually due to atrial arrhythmias

PHYSICAL EXAM FINDINGS

  • Tachycardia if heart failure or atrial fibrillation is present

  • Brief low-amplitude carotid pulse

  • Narrow pulse pressure due to reduced forward stroke volume

  • Signs of congestive heart failure

  • Enlarged apical impulse

  • Auscultation:

    • – Loud P2 if pulmonary hypertension present

    • – S3 with or without heart failure

    • – Blowing holosystolic high-pitched murmur at the apex, radiating to the axilla

  • The murmur characteristically increases in intensity with hand grip exercise but is unchanged in the beat after a premature beat with a compensatory pause

DIFFERENTIAL DIAGNOSIS

  • Functional mitral regurgitation

  • Aortic stenosis

  • Ventricular septal defect

  • Hypertrophic obstructive cardiomyopathy

  • Other causes of dyspnea and orthopnea

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Specific tests for the cause of mitral valve disease such as rheumatoid factor, blood cultures

ELECTROCARDIOGRAPHY

  • Left atrial abnormality

  • Left ventricular hypertrophy

  • Atrial arrhythmias

  • In severe cases, right ventricular and right atrial hypertrophy

IMAGING STUDIES

  • Chest x-ray:

    • – Cardiac enlargement, especially of the left heart chambers

    • – Pulmonary congestion if heart failure present

  • Echocardiography:

    • – Left ventricular and atrial enlargement

    • – Abnormalities of the leaflets, chordae, or annulus may suggest the cause

  • Doppler echocardiography:

    • – Color flow shows regurgitant jet through mitral valve in systole into the left atrium

    • – Severity of regurgitation correlates roughly with jet size

    • – Tricuspid regurgitation should be sought to estimate pulmonary pressures

    • – Regurgitant flow can be calculated as the difference between mitral flow and left ventricular outflow in the absence of significant aortic valve disease

    • – A significant reduction ...

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