Mitral regurgitation Flashcards
(62 cards)
1
Q
Define mitral regurgitation
A
Mitral regurgitation is abnormal retrograde flow of blood from the left ventricle into the left atrium during systole.
2
Q
What is the main cause of mitral regurgitation in developed countries
A
Mitral valve prolapse
3
Q
What is the main cause of mitral regurgitation in developing countries
A
rheumatic heart disease
4
Q
What is the prevalence of mitral regurgitation worldwide
A
> 2% approx 10%
5
Q
What do females have a higher incidence of?
A
Rheumatic mitral valvular disease
6
Q
what do males have a higher incidence of?
A
ischemic mitral regurgitation
7
Q
What is the primary (organic) cause of MR
A
Structural deformities or damage to the valve leaflets, papillary muscles and/or chord tendinae
8
Q
What are the secondary causes of MR?
A
LV wall motion abnormalities or remodelling. Disease of the LV causes the valve to leak
9
Q
How is mitral regurgitation classified?
A
Primary or secondary
acute or chronic
10
Q
What are the causes of acute primary MR?
A
- Ischemic or rupture of the papillary muscles
- rupture of the chord tendinae
- endocarditis that damages the valve leaflets
11
Q
What are the acute causes of secondary MR?
A
Acute Ischemic LV dilation
12
Q
What are the causes of primary chronic MR?
A
- Mitral valve prolapse
- calcification
- rheumatic heart disease
- flail mitral valve leaflets
13
Q
What are the causes of chronic secondary MR?
A
- Dilated cardiomyopathy
- hypertrophic cardiomyopathy
- Aortic insufficiency
- LV dilation and dysfunction
14
Q
Briefly explain the pathophysiology of acute mitral regurgitation
A
- Increased LA pressure causes pulmonary congestion and acute pulmonary edema
- Volume overload of the LV, that causes increased EDV and total stroke volume. However the forward stroke volume (FSV) is decreased as blood is regurgitated. So there is a decrease in cardiac output
15
Q
What are the two main outcomes of acute MR?
A
- Acute pulmonary edema
- Reduced cardiac output
16
Q
What is the pathophysiology of compensated MR?
A
- Volume overload of the left atrium leads to left atrial dilation
- Volume overload of the LV causes eccentric hypertrophy to increase ED V and FSV
17
Q
What is the pathophysiology of decompensated MR?
A
- LV dysfunction leads to impaired ejection causing reduced TSV and FSV
- Reduced cardiac output
- Increased ESV and EDV causing elevated LV pressure
- Blood backs up into the left atrium causing pulmonary edema and pulmonary hypertension
18
Q
What are the clinical features of acute MR?
A
- respiratory stress and potential cardiogenic shock
19
Q
What are the clinical features of compensated MR?
A
Asymptomatic
20
Q
What are the clinical features of decompensated MR?
A
- Left heart failure symptoms (dyspnea, orthopnea and PND)
- Angina
- Syncope
- pulmonary hypertension can cause chest pain
21
Q
What heart sound is heard during mitral regurgitation?
A
- Apical holosystolic/pansystolic murmur that radiates to the axilla
- In severe MR - S3 and P2
22
Q
What are signs of mitral regurgitation?
A
-Displaced PMI
23
Q
What would the echocardiogram of MR show?
A
- Extent of LA and LV enlargement
- pulmonary artery pressure for pulmonary hypertension
- mechanism of MR and evaluate the mitral valve apparatus
24
Q
What would the chest Xray show for acute MR?
A
Normal heart size with pulmonary edema
25
What would the chest Xray show for chronic MR?
- Cardiomegaly
- left atrium and left ventricle enlarged
- Double shadow border of right heart
26
what other tests are done for mitral regurgitation?
1. Colour flow doppler to assess the severity of mitral regurgitation
2. Cardiac catheterisation to determine severity
3. Transesophageal ECHO if TTE is non diagnostic
27
What would the ECG for mitral regurgitation show?
LVH and left atrial abnormality
- Broadened p wave = "p mitrale" for atrial enlargement
28
How is acute MR managed?
Arterial vasodilators
- reduce systemic resistance and increase FSV
Decrease mitral regurgitation
29
What would you do in acute MR if the patient had hypotension?
No vasodilators \
Use intra-aortic balloon coutnerpulsation
30
How is chronic MR managed?
Symptomatic = ACE inhibitors to decrease LV volume and Beta blockers
Surgery is preferred
31
What are the surgical therapy options for MR?
- Mitral valve repair
- percutaneous mitral valve repair
- Mitral valve replacement with to without preservation of the mitral annulus
- transcatheter mitral valve replacement
32
What are the indications for mitral valve surgical therapy?
Indicated for symptomatic and asymptomatic patients.
Chronic MR is preferable treated surgically
EF <0.60 and ESD > 40mm
33
What is a MitraClip?
The Mitraclip is inserted during percutaneous mitral valve repair. Device is implanted via the femoral vein
this is less invasive than open repair but less effective.
34
What is mitral regurgitation (MR)?
An abnormal reversal of blood flow from the LV to the LA
## Footnote
MR is the most common valvular abnormality worldwide, affecting over 2% of the total population.
35
What is the most common valvular abnormality?
Mitral regurgitation (MR)
## Footnote
MR prevalence increases with age.
36
What are the main anatomical components of the mitral valve?
* Two leaflets attached to the annulus fibrosus
* Subvalvular apparatus
* Two papillary muscles arising from the LV
* Chordae tendineae supporting the leaflets
37
What is the etiology of MR in developed countries?
Mitral valve prolapse
38
What is the etiology of MR in developing countries?
Rheumatic heart disease
39
Which gender has a higher incidence of rheumatic mitral valvular disease?
Females
40
Which gender has a higher prevalence of ischemic mitral regurgitation?
Males
41
What percentage of patients with heart failure have MR?
Up to 50%
42
What characterizes primary (organic) MR?
Structural deformity or damage to leaflets, chordae, and/or papillary muscles
43
What characterizes secondary (functional) MR?
LV wall motion abnormalities or remodeling
44
What are causes of acute MR?
* Ischemia and rupture of the papillary muscle
* Acute ischemic LV dilation
* Rupture of the chordae tendinae
* Endocarditis damaging the valve leaflets
45
What are causes of chronic MR?
* Mitral valve prolapse
* Hypertrophic cardiomyopathy
* Calcification of the valve
* Dilated cardiomyopathy
* Rheumatic heart disease
* Aortic insufficiency
* Flail mitral valve leaflets
* LV dilation and LV dysfunction
46
What are the clinical features of acute MR?
Respiratory distress and shock
47
What are the symptoms of chronic compensated MR?
Patients are asymptomatic
48
What are symptoms of chronic decompensated MR?
* Fatigue
* Dyspnea
* Orthopnea
* Paroxysmal nocturnal dyspnea (PND)
* Chest pain
* Hemoptysis
* Peripheral edema
* Abdominal distension
* Swelling of the legs
* Weight loss
* Palpitation
49
What is the auscultatory finding associated with MR?
Apical pansystolic murmur radiating to the left axilla or subscapular region
50
What is a sign of pulmonary hypertension in MR?
Wide split of second heart sound with loud P2
51
What does chest X-ray show in MR?
* Cardiomegaly
* Enlarged left atrium
* Double border of right side of the heart
* Features of left heart failure (Kerley lines, peribronchial cuffing, enlarged pulmonary arteries)
52
What is the goal of managing MR?
Reduce regurgitant fraction and increase stroke volume
53
What is the medical management for chronic asymptomatic MR?
No medical therapy
54
What diuretic is used to reduce pulmonary congestion in MR management?
Furosemide
55
What types of medications are used to reduce afterload in MR?
* Vasodilators (ACE inhibitors)
* Angiotensin receptor blockers
56
What is a surgical treatment option for MR?
* Annuloplasty
* Chordal repair
* Mitral valve repair
* Mitral valve replacement
57
What type of hypertrophy occurs in chronic compensated MR?
Eccentric hypertrophy
58
True or False: Patients with acute MR present with fatigue.
False
59
What are the chest X-ray features of MR?
* Cardiomegaly
* Enlarged left atrium
* Double border of right side of the heart
* Features of left heart failure
60
what is first line therapy for primary MR?
Mitral valve repair
annuloplasty and chordal replacement
61
What are the indicators for MR surgery?
symptomatic MR or asymptomatic MR with EF <60% or ESD >40mm
new onset fibrillation
pulmonary hypertension
62
How do you decide between MR repair and replacement?
If repair is feasible it is preferred to replacement
TTE is crucial to determine the feasibility
