Mitral Regurgitation

Mitral regurgitation, mitral insufficiency or mitral incompetence is a disorder associated with a malfuncitoning mitral valve that allows an abnormal back flow of blood from the left ventricle into the left atrium. This is the most common cause of valvular heart disease.
Causes include functional, annular calcification, rheumatic valvular disease, infective endocarditis, ruptured cord tendon, papillary muscle dysfunction/rupture, connective tissues diseases (Ehlers-Danlos, Marfan's), cardiomyopathy or congenital.

Presentation

Dyspnoea is the most common presenting feature
Fatigue and palpitations
Later stages of the disease increase the risk of thromboembolism as atrial fibrillation is more likely.

History

Duration and type of symptoms
Chest pain - angina history
Syncope - frequency, associated features, warning signs, postal hypotension, movement
Dyspnoea - Dyspnoea - onset, aggravating and relieving factors. Normal exercise tolerance.
Does the patient have any risk factors for developing vascular disease - Hypertension, hypercholesterolaemia, obesity, diabetes, previous acute coronary event/stroke, smoker, lifestyle/occupation, family history of ischaemic heart disease?
Ask about fever, night sweats and other features of deep seated infections such as infective endocarditis
Childhood infections - rheumatic fever
PMHx - previous MI, COPD, pneumonia, valvular disease as a child
FH - history of congenital valve problems. Williams syndrome. Connective tissues disorders - ask about flexibility.

Vital signs / observations

Normal

Examination

Displaced, hyper dynamic apex beat with right ventricular heave
AF common

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On auscultation: Soft S1; split S2, loud P2 in pulmonary hypertension with pan systolic murmur at the apex radiation to the axilla
The more severe the disease, the larger the left ventricle.
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Are there features of cardiac failure - pulmonary oedema, peripheral oedema

Bedside test

ECG - AF, P-mitrale if in sinus rhythm, left ventricular hypertrophy

Laboratory investigations

FBC - anaemia may worsen symptoms

Radiological investigations

CXR - cardiomegaly with left ventricular hypertrophy. Pulmonary oedema. Mitral valve calcification.
Echo - diagnostic and doppler may determine the gradient across the valves. Trans-oesophageal to assess the severity and suitability for repair rather than replacement.

Cardiac catheterisation

Indicated if previous valve surgery, signs of other valvular pathology, angina, severe pulmonary hypertension and calcified mitral valve.
This can assess the valve gradient, LV function and coronary artery disease
Risk of emboli with investigation

Management

If the patient is in atrial fibrillation then rate control is important
Diuretics will reduce cardiac preload and aid any pulmonary venous congestion.

If acute cause of valvular disease such as MI then the first line treatment is valvular surgery. Chronic causes of the disease can be managed medically but surgery is indicated for those with deteriorating symptoms. The aim of surgery is to repair or replace the valve before LV function is irreversibly impaired.

Surgical

Open mitral valvotomy or valve replacement if symptoms not controlled by medication and valvuloplasty is not an option

Follow up

Complications

Pulmonary hypertension is the most common complication
Emboli from AF
Infective endocarditis

Prognosis

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