Mitral regurgitation: Difference between revisions
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− | == |
+ | == Background == |
+ | ===Definition=== |
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− | * Incompetent mitral valve allowing backflow across the annulus |
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− | * Can be ''primary'', from myxomatous degeneration or senescence, or ''secondary'', from LV dilatation and functional regurgitation |
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+ | *Incompetent mitral valve allowing backflow across the annulus |
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− | == Etiology == |
||
+ | *Can be ''primary'', from myxomatous degeneration or senescence, or ''secondary'', from LV dilatation and functional regurgitation |
||
+ | ===Etiology=== |
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− | * Inflammatory |
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− | ** Rheumatic heart disease |
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− | ** Lupus |
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− | ** Scleroderma |
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− | ** Rheumatoid arthritis |
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− | * Degenerative |
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− | ** Myxomatous degeneration (MVP) |
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− | ** Marfan syndrome |
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− | ** Ehlers-Danlos syndrome |
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− | * Infective endocarditis, after healing |
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− | * Structural |
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− | ** Ruptured chordae tendinae (spontaneous, post-MI, MVP, trauma, IE) |
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− | ** Ruptured or dysfunctional papillary muscle (MI) |
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− | ** Mitral annular dilatation from LV dysfunction (also called secondary MR) |
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− | ** Hypertrophic cardiomyopathy (due to systolic anterior motion of the MV; SAM) |
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− | ** Paravalvular leak of prosthetic valve |
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− | * Congenital |
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− | ** MV cleft or fenestration |
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− | ** Parachute mitral valve |
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+ | *Inflammatory |
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− | == Pathophysiology == |
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+ | **[[Rheumatic heart disease]] |
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+ | **[[Systemic lupus erythematosus]] |
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+ | **[[Scleroderma]] |
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+ | **[[Rheumatoid arthritis]] |
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+ | *Degenerative |
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+ | **Myxomatous degeneration (MVP) |
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+ | **[[Marfan syndrome]] |
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+ | **[[Ehlers-Danlos syndrome]] |
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+ | *[[Infective endocarditis]], after healing |
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+ | *Structural |
||
+ | **Ruptured chordae tendinae (spontaneous, post-MI, MVP, trauma, IE) |
||
+ | **Ruptured or dysfunctional papillary muscle (MI) |
||
+ | **Mitral annular dilatation from LV dysfunction (also called secondary MR) |
||
+ | **Hypertrophic cardiomyopathy (due to systolic anterior motion of the MV; SAM) |
||
+ | **Paravalvular leak of prosthetic valve |
||
+ | *Congenital |
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+ | **MV cleft or fenestration |
||
+ | **Parachute mitral valve |
||
+ | ===Pathophysiology=== |
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− | * LV compensates by eccentric hypertrophy (increased LV end-diastolic volume) |
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− | * LVEF supra-normal >60% |
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− | * LA dilates to compensate for MR and maintain normal LA pressure |
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+ | *LV compensates by eccentric hypertrophy (increased LV end-diastolic volume) |
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− | == Grading == |
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+ | *LVEF supra-normal >60% |
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+ | *LA dilates to compensate for MR and maintain normal LA pressure |
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+ | ===Grading=== |
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− | * Severe |
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− | ** Central jet >40% of LA |
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− | ** Holosystolic eccentric jet of MR |
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− | ** Vena contracta ≥0.7cm |
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− | ** Regurgitant volume ≥60ml |
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− | ** Regurgitant fraction ≥50% |
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− | ** ERO ≥0.4cm2 |
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− | ** Other findings: LA enlargement and high RVSP |
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− | * Secondary MR |
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− | * Severe |
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− | ** ERO ≥0.2 |
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− | ** Regurgitant volume ≥30ml |
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− | ** Regurgitant fraction ≥50% |
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− | * Progressive |
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− | ** Otherwise |
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+ | *Severe |
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− | == Clinical Presentation == |
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+ | **Central jet >40% of LA |
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+ | **Holosystolic eccentric jet of MR |
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+ | **Vena contracta ≥0.7cm |
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+ | **Regurgitant volume ≥60ml |
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+ | **Regurgitant fraction ≥50% |
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+ | **ERO ≥0.4cm2 |
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+ | **Other findings: LA enlargement and high RVSP |
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+ | *Secondary MR |
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+ | *Severe |
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+ | **ERO ≥0.2 |
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+ | **Regurgitant volume ≥30ml |
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+ | **Regurgitant fraction ≥50% |
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+ | *Progressive |
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+ | **Otherwise |
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+ | ==Clinical Manifestations== |
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− | === Physical Examination === |
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+ | ===Physical Examination=== |
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− | * Palpation |
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− | ** PMI is prominent and displaced left |
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− | ** Systolic expansion of LA may be palpable in RSB |
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− | * Auscultation |
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− | ** Soft S1 |
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− | ** Widely split S2 (A2 occurs early because decreased forward flow over the aortic valve) |
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− | ** Holosystolic, blowing, high-pitched murmur at the apex |
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− | ** May hear S3 |
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+ | *Palpation |
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− | == Investigations == |
||
+ | **PMI is prominent and displaced left |
||
+ | **Systolic expansion of LA may be palpable in RSB |
||
+ | *Auscultation |
||
+ | **Soft S1 |
||
+ | **Widely split S2 (A2 occurs early because decreased forward flow over the aortic valve) |
||
+ | **Holosystolic, blowing, high-pitched murmur at the apex |
||
+ | **May hear S3 |
||
+ | ==Investigations== |
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− | * Consider TEE if severity or mechanism is unclear fro TEE, especially if eccentric jet |
||
− | * Consider cardiac MRI if volumes are unclear from TTE |
||
− | * Consider exercise echo if discrepancy between severity on TTE and symptoms |
||
+ | *Consider TEE if severity or mechanism is unclear fro TEE, especially if eccentric jet |
||
− | == Management == |
||
+ | *Consider cardiac MRI if volumes are unclear from TTE |
||
+ | *Consider exercise echo if discrepancy between severity on TTE and symptoms |
||
+ | ==Management== |
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− | * ACEi, beta blocker, MRA for HFrEF if surgery not planned |
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+ | |||
− | * Don't use vasodilators unless hypertensive |
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+ | *[[ACEi]], [[beta blocker]], [[spironolactone]] for [[HFrEF]] if surgery not planned |
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− | * Surgery: repair preferred to replacement when possible |
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+ | *Don't use vasodilators unless [[Hypertension|hypertensive]] |
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− | ** Symptomatic severe LVEF >30% |
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+ | *Surgery: repair preferred to replacement when possible |
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− | ** Asymptomatic severe with LVEF ≤060% or LVESD ≥40mm |
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+ | **Symptomatic severe LVEF >30% |
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− | ** Undergoing another cardiac surgery |
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− | ** |
+ | **Asymptomatic severe with LVEF ≤060% or LVESD ≥40mm |
+ | **Undergoing another cardiac surgery |
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− | ** Asymptomatic severe with new AFib or resting pHTN |
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+ | **Asymptomatic chronic severe with normal LVEF and dimesion in whome likelihood of successful repair iss >95% and expected mortality <1% |
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− | * Secondary MR |
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+ | **Asymptomatic severe with new AFib or resting pHTN |
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− | ** Treat the LV first per heart failure guidelines |
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+ | *Secondary MR |
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− | ** Consider CRT (cardiac resynchronization therapy) before valvular intervention |
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+ | **Treat the LV first per heart failure guidelines |
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− | ** Surgery if |
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+ | **Consider [[cardiac resynchronization therapy]] before valvular intervention |
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− | *** Undergoing another cardiac surgery like CABG and AVR |
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+ | **Surgery if |
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− | *** Consider for severe symptomatic patients |
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+ | ***Undergoing another cardiac surgery like [[CABG]] and [[aortic valve replacement]] |
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+ | ***Consider for severe symptomatic patients |
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[[Category:Cardiology]] |
[[Category:Cardiology]] |
Latest revision as of 07:10, 3 August 2020
Background
Definition
- Incompetent mitral valve allowing backflow across the annulus
- Can be primary, from myxomatous degeneration or senescence, or secondary, from LV dilatation and functional regurgitation
Etiology
- Inflammatory
- Degenerative
- Myxomatous degeneration (MVP)
- Marfan syndrome
- Ehlers-Danlos syndrome
- Infective endocarditis, after healing
- Structural
- Ruptured chordae tendinae (spontaneous, post-MI, MVP, trauma, IE)
- Ruptured or dysfunctional papillary muscle (MI)
- Mitral annular dilatation from LV dysfunction (also called secondary MR)
- Hypertrophic cardiomyopathy (due to systolic anterior motion of the MV; SAM)
- Paravalvular leak of prosthetic valve
- Congenital
- MV cleft or fenestration
- Parachute mitral valve
Pathophysiology
- LV compensates by eccentric hypertrophy (increased LV end-diastolic volume)
- LVEF supra-normal >60%
- LA dilates to compensate for MR and maintain normal LA pressure
Grading
- Severe
- Central jet >40% of LA
- Holosystolic eccentric jet of MR
- Vena contracta ≥0.7cm
- Regurgitant volume ≥60ml
- Regurgitant fraction ≥50%
- ERO ≥0.4cm2
- Other findings: LA enlargement and high RVSP
- Secondary MR
- Severe
- ERO ≥0.2
- Regurgitant volume ≥30ml
- Regurgitant fraction ≥50%
- Progressive
- Otherwise
Clinical Manifestations
Physical Examination
- Palpation
- PMI is prominent and displaced left
- Systolic expansion of LA may be palpable in RSB
- Auscultation
- Soft S1
- Widely split S2 (A2 occurs early because decreased forward flow over the aortic valve)
- Holosystolic, blowing, high-pitched murmur at the apex
- May hear S3
Investigations
- Consider TEE if severity or mechanism is unclear fro TEE, especially if eccentric jet
- Consider cardiac MRI if volumes are unclear from TTE
- Consider exercise echo if discrepancy between severity on TTE and symptoms
Management
- ACEi, beta blocker, spironolactone for HFrEF if surgery not planned
- Don't use vasodilators unless hypertensive
- Surgery: repair preferred to replacement when possible
- Symptomatic severe LVEF >30%
- Asymptomatic severe with LVEF ≤060% or LVESD ≥40mm
- Undergoing another cardiac surgery
- Asymptomatic chronic severe with normal LVEF and dimesion in whome likelihood of successful repair iss >95% and expected mortality <1%
- Asymptomatic severe with new AFib or resting pHTN
- Secondary MR
- Treat the LV first per heart failure guidelines
- Consider cardiac resynchronization therapy before valvular intervention
- Surgery if
- Undergoing another cardiac surgery like CABG and aortic valve replacement
- Consider for severe symptomatic patients