Mitral Regurgitation - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Palpitations The increased stroke volume is sensed as a "palpitation". In addition, atrial fibrillation complicating mitral regurgitation can contribute to palpitations as well. Also, in mitral valve prolapse, which is a cause of mitral regurgitation, there can be associated abnormal ventricular contractions and atrial or ventricular arrhythmias which lead to palpitations Palpitations
The increased stroke volume is sensed as a "palpitation". In addition, atrial fibrillation complicating mitral regurgitation can contribute to palpitations as well. Also, in mitral valve prolapse, which is a cause of mitral regurgitation, there can be associated abnormal ventricular contractions and atrial or ventricular arrhythmias which lead to palpitations
The patient can be asymptomatic Patients with chronic, mild to moderate, isolated mitral regurgitation are usually asymptomatic because this form of volume overload is well tolerated The patient can be asymptomatic
Patients with chronic, mild to moderate, isolated mitral regurgitation are usually asymptomatic because this form of volume overload is well tolerated
Fatigue and lethargy Due to the low cardiac output Fatigue and lethargy
Due to the low cardiac output
Dyspnea on exertion Due to the pulmonary venous hypertension which occurs as a direct result of the mitral regurgitation and secondarily due to left ventricular failure Dyspnea on exertion
Due to the pulmonary venous hypertension which occurs as a direct result of the mitral regurgitation and secondarily due to left ventricular failure
Orthopnea Due to the pulmonary venous hypertension which occurs as a direct result of the mitral regurgitation and secondarily due to left ventricular failure Orthopnea
Due to the pulmonary venous hypertension which occurs as a direct result of the mitral regurgitation and secondarily due to left ventricular failure
Cough Due to pulmonary hypertension which can complicate long-standing mitral regurgitation Cough
Due to pulmonary hypertension which can complicate long-standing mitral regurgitation
Hemoptysis Due to pulmonary hypertension which can complicate long-standing mitral regurgitation Hemoptysis
Due to pulmonary hypertension which can complicate long-standing mitral regurgitation
Chest pain Due to pulmonary hypertension which can complicate long-standing mitral regurgitation Chest pain
Due to pulmonary hypertension which can complicate long-standing mitral regurgitation
Sudden-onset difficulty in breathing with production of pink frothy sputum (features of acute pulmonary edema) Sudden-onset, severe mitral regurgitation usually presents with acute pulmonary edema Sudden-onset difficulty in breathing with production of pink frothy sputum (features of acute pulmonary edema)
Sudden-onset, severe mitral regurgitation usually presents with acute pulmonary edema
Atypical chest pain- usually it is a left submammary pain with a stabbing quality. It may even be substernal, aching and severe Symptom of mitral valve prolapse, which is a cause of mitral regurgitation Atypical chest pain- usually it is a left submammary pain with a stabbing quality. It may even be substernal, aching and severe
Symptom of mitral valve prolapse, which is a cause of mitral regurgitation
Typical angina-like chest pain Can rarely occur in mitral valve prolapse, which is a cause of mitral regurgitation Typical angina-like chest pain
Can rarely occur in mitral valve prolapse, which is a cause of mitral regurgitation
Light-headedness and syncope In mitral valve prolapse, which is a cause of mitral regurgitation, there can be associated abnormal ventricular contractions and atrial or ventricular arrhythmias which lead to these symptoms Light-headedness and syncope
In mitral valve prolapse, which is a cause of mitral regurgitation, there can be associated abnormal ventricular contractions and atrial or ventricular arrhythmias which lead to these symptoms
Swollen ankles Due to right heart failure which occurs as a result of left heart failure and pulmonary hypertension Swollen ankles
Due to right heart failure which occurs as a result of left heart failure and pulmonary hypertension
Progressive enlargement of the abdomen Due to right heart failure which occurs as a result of left heart failure and pulmonary hypertension Progressive enlargement of the abdomen
Due to right heart failure which occurs as a result of left heart failure and pulmonary hypertension
Prolonged fever Subacute infective endocarditis complicating mitral regurgitation Prolonged fever
Subacute infective endocarditis complicating mitral regurgitation
Weakness of one side of the body Thromboembolism(which can be a complication of mitral regurgitation) leading to an ischemic stroke or transient ischemic attack. Mitral valve prolapse, which is a cause of mitral regurgitation, is associated with a risk of embolic stroke or transient ischemic attack due to endothelial disruption Weakness of one side of the body
Thromboembolism(which can be a complication of mitral regurgitation) leading to an ischemic stroke or transient ischemic attack. Mitral valve prolapse, which is a cause of mitral regurgitation, is associated with a risk of embolic stroke or transient ischemic attack due to endothelial disruption
Painful lower limb Thromboembolism(which can be a complication of mitral regurgitation) leading to an ischemic limb Painful lower limb
Thromboembolism(which can be a complication of mitral regurgitation) leading to an ischemic limb
Sudden cardiac death Due to a fatal ventricular arrhythmia which can rarely complicate mitral valve prolapse. Mitral valve prolapse is a cause of mitral regurgitation Sudden cardiac death
Due to a fatal ventricular arrhythmia which can rarely complicate mitral valve prolapse. Mitral valve prolapse is a cause of mitral regurgitation

Clinicals - Examination

Fact Explanation
Pulse may be irregularly irregular Atrial fibrillation complicating mitral regurgitation leads to an irregularly irregular pulse. Atrial fibrillation occurs as a consequence of the atrial dilatation Pulse may be irregularly irregular
Atrial fibrillation complicating mitral regurgitation leads to an irregularly irregular pulse. Atrial fibrillation occurs as a consequence of the atrial dilatation
Laterally displaced, thrusting (forceful) apex beat (a displaced, hyperdynamic apex beat) Regurgitated blood returning to the left ventricle leading to a volume overload, which in turn leads to enlargement of the left ventricle Laterally displaced, thrusting (forceful) apex beat (a displaced, hyperdynamic apex beat)
Regurgitated blood returning to the left ventricle leading to a volume overload, which in turn leads to enlargement of the left ventricle
Systolic thrill may be palpable Severe mitral regurgitation will lead to a systolic thrill Systolic thrill may be palpable
Severe mitral regurgitation will lead to a systolic thrill
Soft or even absent, first heart sound Due to the incomplete apposition of the valve cusps and their partial closure by the time ventricular systole begins Soft or even absent, first heart sound
Due to the incomplete apposition of the valve cusps and their partial closure by the time ventricular systole begins
Wide, physiologic splitting of the second heart sound Due to the fact that the aortic valve may close prematurely in patients with severe mitral regurgitation Wide, physiologic splitting of the second heart sound
Due to the fact that the aortic valve may close prematurely in patients with severe mitral regurgitation
Prominent third heart sound (apical third heart sound) Due to the sudden rush of blood back into the dilated left ventricle, across the mitral valve, in early diastole Prominent third heart sound (apical third heart sound)
Due to the sudden rush of blood back into the dilated left ventricle, across the mitral valve, in early diastole
Fourth heart sound It is often present in patients with acute, severe mitral regurgitation who are in sinus rhythm Fourth heart sound
It is often present in patients with acute, severe mitral regurgitation who are in sinus rhythm
Pansystolic murmur being loudest at the apex, but radiating widely over the precordium and into the axilla Due to the regurgitation of blood from the left ventricle, across an incompetent mitral valve, throughout the whole of systole Pansystolic murmur being loudest at the apex, but radiating widely over the precordium and into the axilla
Due to the regurgitation of blood from the left ventricle, across an incompetent mitral valve, throughout the whole of systole
Short mid-diastolic flow murmur following the third heart sound Increased forward flow through the mitral valve Short mid-diastolic flow murmur following the third heart sound
Increased forward flow through the mitral valve
Holosystolic (pansystolic) murmur transmitted to the base of the heart (i.e. the neck) In patients with ruptured chordae tendineae or primary involvement of the posterior mitral leaflet with prolapse or flail, the regurgitant jet is eccentric, directed anteriorly, and strikes the left atrial wall adjacent to the aortic root leading to transmission of the murmur to the base of the heart Holosystolic (pansystolic) murmur transmitted to the base of the heart (i.e. the neck)
In patients with ruptured chordae tendineae or primary involvement of the posterior mitral leaflet with prolapse or flail, the regurgitant jet is eccentric, directed anteriorly, and strikes the left atrial wall adjacent to the aortic root leading to transmission of the murmur to the base of the heart
Holosystolic (pansystolic) murmur with a "cooing" or a "sea gull" quality In patients with mitral regurgitation and ruptured chordae tendineae Holosystolic (pansystolic) murmur with a "cooing" or a "sea gull" quality
In patients with mitral regurgitation and ruptured chordae tendineae
Holosystolic (pansystolic) murmur with a musical quality In patients with mitral regurgitation and a flail leaflet Holosystolic (pansystolic) murmur with a musical quality
In patients with mitral regurgitation and a flail leaflet
Holosystolic (pansystolic) murmur which is intensified by isometric exercise (e.g. handgrip) In patients with chronic mitral regurgitation not due to mitral valve prolapse Holosystolic (pansystolic) murmur which is intensified by isometric exercise (e.g. handgrip)
In patients with chronic mitral regurgitation not due to mitral valve prolapse
Holosystolic (pansystolic) murmur which is during the strain phase of the Valsalva maneuver In patients with chronic mitral regurgitation not due to mitral valve prolapse, there is an associated decrease in the left ventricular preload leading to this phenomenon Holosystolic (pansystolic) murmur which is during the strain phase of the Valsalva maneuver
In patients with chronic mitral regurgitation not due to mitral valve prolapse, there is an associated decrease in the left ventricular preload leading to this phenomenon
Mid-systolic click which may be followed by a late systolic murmur This "click" is seen in mitral valve prolapse(MVP) (which is a cause of mitral regurgitation) due to the sudden prolapse of the valve and the tensing of the chordae tendineae that occurs during systole. The late-systolic murmur occurs if there is some regurgitation of blood. This murmur lengthens and becomes pansystolic as the regurgitation increases in severity Mid-systolic click which may be followed by a late systolic murmur
This "click" is seen in mitral valve prolapse(MVP) (which is a cause of mitral regurgitation) due to the sudden prolapse of the valve and the tensing of the chordae tendineae that occurs during systole. The late-systolic murmur occurs if there is some regurgitation of blood. This murmur lengthens and becomes pansystolic as the regurgitation increases in severity
Mid-systolic click and subsequent murmur occurring earlier with standing and during the strain phase of the Valsalva maneuver Any intervention that decreases the left ventricular volume, exaggerates the propensity of the mitral valve leaflet to prolapse in MVP Mid-systolic click and subsequent murmur occurring earlier with standing and during the strain phase of the Valsalva maneuver
Any intervention that decreases the left ventricular volume, exaggerates the propensity of the mitral valve leaflet to prolapse in MVP
Mid-systolic click and subsequent murmur occurring later with squatting and isometric exercise Any intervention that increases the left ventricular volume, reduces MVP Mid-systolic click and subsequent murmur occurring later with squatting and isometric exercise
Any intervention that increases the left ventricular volume, reduces MVP
Bi-basal fine crepitations Pulmonary edema due left heart failure, which is a complication of mitral regurgitation Bi-basal fine crepitations
Pulmonary edema due left heart failure, which is a complication of mitral regurgitation
Signs related to pleural effusion- reduced chest movements, reduced chest expansion and reduced breath sounds on the affected side with shift of the mediastinum to the opposite side Pleural effusions can occur due to left heart failure, which is a complication of mitral regurgitation Signs related to pleural effusion- reduced chest movements, reduced chest expansion and reduced breath sounds on the affected side with shift of the mediastinum to the opposite side
Pleural effusions can occur due to left heart failure, which is a complication of mitral regurgitation
Hypotension Due to heart failure, which is a complication of mitral regurgitation Hypotension
Due to heart failure, which is a complication of mitral regurgitation
Large 'a' wave and/or prominent 'v' wave in jugular venous wave form Due to pulmonary hypertension which occurs as a complication of mitral regurgitation Large 'a' wave and/or prominent 'v' wave in jugular venous wave form
Due to pulmonary hypertension which occurs as a complication of mitral regurgitation
Loud pulmonary component of the second heart sound Due to pulmonary hypertension which occurs as a complication of mitral regurgitation Loud pulmonary component of the second heart sound
Due to pulmonary hypertension which occurs as a complication of mitral regurgitation
Early diastolic murmur in the pulmonary area (Graham Steell murmur) Due to pulmonary regurgitation which occurs as a consequence of pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation Early diastolic murmur in the pulmonary area (Graham Steell murmur)
Due to pulmonary regurgitation which occurs as a consequence of pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation
Right ventricular(parasternal) heave Due to the right ventricular enlargement which occurs as a result of the pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation Right ventricular(parasternal) heave
Due to the right ventricular enlargement which occurs as a result of the pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation
Large jugular 'cv' wave Due to the tricuspid regurgitation which occurs as a result of the right ventricular enlargement which occurs as a consequence of the pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation Large jugular 'cv' wave
Due to the tricuspid regurgitation which occurs as a result of the right ventricular enlargement which occurs as a consequence of the pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation
Murmur of tricuspid regurgitation (secondary tricuspid regurgitation) Due to the tricuspid regurgitation which occurs as a result of the right ventricular enlargement which occurs as a consequence of the pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation Murmur of tricuspid regurgitation (secondary tricuspid regurgitation)
Due to the tricuspid regurgitation which occurs as a result of the right ventricular enlargement which occurs as a consequence of the pulmonary hypertension. Pulmonary hypertension is a complication of mitral regurgitation
Peripheral edema- Bi-lateral pitting ankle edema, sacral edema Due to the right ventricular failure that is a complication of mitral regurgitation Peripheral edema- Bi-lateral pitting ankle edema, sacral edema
Due to the right ventricular failure that is a complication of mitral regurgitation
Ascites Due to the right ventricular failure that is a complication of mitral regurgitation Ascites
Due to the right ventricular failure that is a complication of mitral regurgitation
Hepatomegaly Due to the right ventricular failure that is a complication of mitral regurgitation Hepatomegaly
Due to the right ventricular failure that is a complication of mitral regurgitation
Elevated jugular venous pressure(JVP) Due to the right ventricular failure that is a complication of mitral regurgitation Elevated jugular venous pressure(JVP)
Due to the right ventricular failure that is a complication of mitral regurgitation
Distended neck veins Due to the right ventricular failure that is a complication of mitral regurgitation Distended neck veins
Due to the right ventricular failure that is a complication of mitral regurgitation
Cardiac cachexia- loss of lean (non-edematous) body mass Occurs following the onset of heart failure, which is a complication of mitral regurgitation Cardiac cachexia- loss of lean (non-edematous) body mass
Occurs following the onset of heart failure, which is a complication of mitral regurgitation

Investigations - Diagnosis

Fact Explanation
Electrocardiogram (ECG) To detect changes which occur as a result of mitral regurgitation. Bifid P waves due to left atrial enlargement. Tall R waves in the left lateral leads (leads I and V6) and deep S waves in the right-sided precordial leads (leads V1 & V2) which indicate left ventricular enlargement. Atrial fibrillation may be present Electrocardiogram (ECG)
To detect changes which occur as a result of mitral regurgitation. Bifid P waves due to left atrial enlargement. Tall R waves in the left lateral leads (leads I and V6) and deep S waves in the right-sided precordial leads (leads V1 & V2) which indicate left ventricular enlargement. Atrial fibrillation may be present
Chest X-ray (CXR) To detect changes which occur as a result of mitral regurgitation. CXR may show left atrial and ventricular enlargement. It may also show cardiomegaly with an increased cardio-thoracic ratio. Valve calcification may be seen. Changes related to heart failure may also be seen. Pulmonary edema may be seen in acute mitral regurgitation Chest X-ray (CXR)
To detect changes which occur as a result of mitral regurgitation. CXR may show left atrial and ventricular enlargement. It may also show cardiomegaly with an increased cardio-thoracic ratio. Valve calcification may be seen. Changes related to heart failure may also be seen. Pulmonary edema may be seen in acute mitral regurgitation
Transthoracic echocardiography (TTE) Confirms the diagnosis of mitral regurgitation (MR) and detects the changes that occur as a result of MR. CW Doppler can detect the velocity of the regurgitant jet. The severity of the condition and structure of the mitral valve can also be assessed. In patients with MVP, the prolapse of one or both valve leaflets into the left atrium can be detected Transthoracic echocardiography (TTE)
Confirms the diagnosis of mitral regurgitation (MR) and detects the changes that occur as a result of MR. CW Doppler can detect the velocity of the regurgitant jet. The severity of the condition and structure of the mitral valve can also be assessed. In patients with MVP, the prolapse of one or both valve leaflets into the left atrium can be detected
Transesophageal echocardiography (TEE) Can confirm the diagnosis of mitral regurgitation (MR). Detects the changes that occur as a result of MR. Helps to identify structural valve abnormalities prior to surgery. TEE provides better detail than TTE Transesophageal echocardiography (TEE)
Can confirm the diagnosis of mitral regurgitation (MR). Detects the changes that occur as a result of MR. Helps to identify structural valve abnormalities prior to surgery. TEE provides better detail than TTE
Cardiac catheterization Can assess the severity of mitral regurgitation (MR). Also enables the detection of pulmonary hypertension which is a complication of MR. In addition, detection of co-existing coronary artery disease is also possible Cardiac catheterization
Can assess the severity of mitral regurgitation (MR). Also enables the detection of pulmonary hypertension which is a complication of MR. In addition, detection of co-existing coronary artery disease is also possible

Management - Supportive

Fact Explanation
Patient advice with regards to infective endocarditis- Patients with mitral regurgitation are at risk of infective endocarditis
Patients should be educated on the benefits and risks of antibiotic prophylaxis, and an
explanation of why antibiotic prophylaxis is no longer routinely recommended.The importance of maintaining good oral health. Symptoms that may indicate infective endocarditis and when to seek expert advice. The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing
Patient advice with regards to infective endocarditis-
Patients with mitral regurgitation are at risk of infective endocarditis
Patients should be educated on the benefits and risks of antibiotic prophylaxis, and an
explanation of why antibiotic prophylaxis is no longer routinely recommended.The importance of maintaining good oral health. Symptoms that may indicate infective endocarditis and when to seek expert advice. The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing

Management - Specific

Fact Explanation
Follow-up with serial echocardiography For patients with mild, asymptomatic mitral regurgitation. Enables the detection of any progression of the regurgitation Follow-up with serial echocardiography
For patients with mild, asymptomatic mitral regurgitation. Enables the detection of any progression of the regurgitation
Angiotensin-II converting enzyme inhibitors (ACE inhibitors) For patients who have mitral regurgitation(MR) and systemic hypertension. ACE inhibitors have a vasodilatory action. This reduces the afterload. High afterload may worsen the degree of regurgitation

In addition, ACE inhibitors are used in the treatment of heart failure, which is a complication of MR. ACE inhibitors are used in the evidence-based treatment of heart failure

ACE inhibitors are also used in the management of patients who are not considered appropriate for surgical intervention or in whom surgery will be considered at a later date

Note- There are no large, long-term prospective studies to substantiate the use of vasodilators for the treatment of chronic, isolated severe MR with preserved LV systolic function in the absence of systemic hypertension
Angiotensin-II converting enzyme inhibitors (ACE inhibitors)
For patients who have mitral regurgitation(MR) and systemic hypertension. ACE inhibitors have a vasodilatory action. This reduces the afterload. High afterload may worsen the degree of regurgitation

In addition, ACE inhibitors are used in the treatment of heart failure, which is a complication of MR. ACE inhibitors are used in the evidence-based treatment of heart failure

ACE inhibitors are also used in the management of patients who are not considered appropriate for surgical intervention or in whom surgery will be considered at a later date

Note- There are no large, long-term prospective studies to substantiate the use of vasodilators for the treatment of chronic, isolated severe MR with preserved LV systolic function in the absence of systemic hypertension
Diuretics For patients who have developed heart failure as a complication of mitral regurgitation (MR).

Diuretics are used in the evidence-based treatment of heart failure.

Diuretics are also used in the management of patients who are not considered appropriate for surgical intervention or in whom surgery will be considered at a later date

Diuretics are also used in the initial medical management of patients with acute severe MR
Diuretics
For patients who have developed heart failure as a complication of mitral regurgitation (MR).

Diuretics are used in the evidence-based treatment of heart failure.

Diuretics are also used in the management of patients who are not considered appropriate for surgical intervention or in whom surgery will be considered at a later date

Diuretics are also used in the initial medical management of patients with acute severe MR
Intra-venous vasodilators (particularly sodium nitroprusside) Used in the initial medical management of patients with acute severe mitral regurgitation Intra-venous vasodilators (particularly sodium nitroprusside)
Used in the initial medical management of patients with acute severe mitral regurgitation
Intra-aortic balloon counterpulsation Used in the initial medical management of patients with acute severe mitral regurgitation Intra-aortic balloon counterpulsation
Used in the initial medical management of patients with acute severe mitral regurgitation
Anticoagulants Anticoagulation is necessary if atrial fibrillation (AF) is present, in order to prevent the formation of an intra-cardiac thrombus

Anticoagulation is also indicated in mitral valve prolapse (MVP) with AF and severe mitral regurgitation to prevent thromboembolism

Also used in patients who have had mitral valve replacement
Anticoagulants
Anticoagulation is necessary if atrial fibrillation (AF) is present, in order to prevent the formation of an intra-cardiac thrombus

Anticoagulation is also indicated in mitral valve prolapse (MVP) with AF and severe mitral regurgitation to prevent thromboembolism

Also used in patients who have had mitral valve replacement
Beta-blockers For mitral valve prolapse(MVP) with symptoms such as atypical chest pain and palpitations Beta-blockers
For mitral valve prolapse(MVP) with symptoms such as atypical chest pain and palpitations
Anti-arrhythmic drugs For mitral valve prolapse(MVP) with an arrhythmia Anti-arrhythmic drugs
For mitral valve prolapse(MVP) with an arrhythmia
Elective surgery- Mitral valve repair or mitral valve replacement If there is any evidence of progressive cardiac enlargement or echocardiographic evidence of deteriorating left ventricular function, early surgical intervention is warranted even in the absence of symptoms

The advantages of surgical intervention are diminished in more advanced disease

Mitral valve repair is used to treat mitral valve prolapse (MVP) with severe mitral regurgitation because of the risk of sudden death
Elective surgery- Mitral valve repair or mitral valve replacement
If there is any evidence of progressive cardiac enlargement or echocardiographic evidence of deteriorating left ventricular function, early surgical intervention is warranted even in the absence of symptoms

The advantages of surgical intervention are diminished in more advanced disease

Mitral valve repair is used to treat mitral valve prolapse (MVP) with severe mitral regurgitation because of the risk of sudden death
Emergency mitral valve replacement Used for acute severe mitral regurgitation, after urgent stabilization Emergency mitral valve replacement
Used for acute severe mitral regurgitation, after urgent stabilization
Prophylaxis against infective endocarditis prior to interventions For patients who have undergone mitral valve replacement (i.e. patients with prosthetic heart valves)

For patients who have undergone mitral valve repair

For patients with mitral valve prolapse and auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography

These patients are deemed to be at high risk for infective endocarditis
Prophylaxis against infective endocarditis prior to interventions
For patients who have undergone mitral valve replacement (i.e. patients with prosthetic heart valves)

For patients who have undergone mitral valve repair

For patients with mitral valve prolapse and auscultatory evidence of valvular regurgitation and/or thickened leaflets on echocardiography

These patients are deemed to be at high risk for infective endocarditis

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