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8/7/2019 Mitral Regurgitation(Mitral Insufficiency, Mitral Incompetence)
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Mitral regurgitation(mitral
insufficiency, mitral incompetence)
mitral valve doesnot close properly when theheart pumps the blood
Abnormal leaking of blood from left ventriclethrough mitral valve into the left atrium.
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Anatomy
2 valve leaflets
Annulus
Papillary musclesChordae tendinae
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Pathology
Any dysfunction of above structure leads to
mitral regurgitation.
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Etiology
1. Mitral valve prolapse
2. Ischaemic heart diseases
3. Rheumatic fever4. Marfans syndrome
5. Secondary mitral regurgitation
Eg, aortic insufficiency
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Acute mitral regurgitation
1. Endocarditis
2. Papillary muscle rupture
3. Mvp4. Chest trauma
5. Cardiac surgery
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Pathophysiology
1. Acute phase
2. Chronic compensated phase
3. Chronic decompensated phase
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Acute phase
Sudden rupture of chordae tendinae or
papillary muscles
Volume overload of left ventricle and leftatrium
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Acute phase
Volume overload of left ventricle
Forward stroke+regurgitant volume
Starlings law More SV
Later LV volume
Loss Contractility
dysfunction
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Continued acute phase
Regurgitant volume in LA
Volume + pressure
Pulmonary conges.
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Chronic compensated phase
If mitral regurgitation develops slowly over
months and years
Or if can be managed medically
Hypertrophy Diastolic vol.Strokevolume
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Chronic compensated phase
Vol overload
Enlargement of LA
Filling pressureDrainage from pulmonary veins
Congestion
So asymptomatic,May be normal exercise tolerance.
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Chronic decompensated
Eventually LV may be dysfunctional by not
contracting.
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Chronic decompensated
Sv
Co
E
ndsystolic volFilling pressure
Pulmonary congestion
Dilatation
Mitral valve annulus dilatation
Mitral regurgitation
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Symptoms
Acute
Chf
i. Shortness of breathii. Pulmonary oedema
iii. Orthopnea
iv. Paroxysmal nocturnal dyspnoea
v. Fatiguability
vi. Decreased exercise tolerance
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Symptoms
Chronic compensated
i. Asymptomatic
ii. Normal exercise toleranceiii. No evidence of heart failure
iv. But sensitive to vascular volume shifts
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Signs
Pulse
-High volume,collapsing in severe
-Irregular rhythm in atrial fibrillation Jugular veins
-Disappearance of a wave in atrial fibrillation
- Prominent a wave in pulmonary hypertension
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signs
Blood pressure
Wide pulse pressure in severe mitral
regurgitation
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Inspection
Apex beat shifted laterally and downward
Systolic thrill at apex
Sustained left parasternal heave and palpablepulmonary component of second heart sound
in pulmonary hypertension
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Auscultation
First heart sound usually soft
Severe mitral stenosis, S2 widely split due to
arotic vavle closure occuring early Pulmonary component of P2 is loud in
pulmonary hypertension
Pulmonary ejection sound in pulmonaryhypertension
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murmur
Pansystolic murmur heard best at apex
radiating to the axilla and left interscapular
area
Other murmur
- ejection systolic murmur in pulmonary
hypertension
-pansystolic murmur at left sternal border due
to functional tricuspid regurgitation
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Investigations
Ecg
-left atrial enlargement
-Left ventricular dilatationa and hypertrophy-atrial fibrillation
Echocardiogram
-enlarged left atrium
_hyperdynamic left ventricle
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investigations
Chest radiography
-cardiomegaly with left atrial and left ventricular
enlargement-calcification of mitral valve
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management
1. Atrial fibrillation
2. Heart failure
3. Restriction of physical activity4. Treatment based on etiology
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Surgical management
Mitral valvuloplasty
Mitral valve replacementS