#mitralregurgitation #MR #Hindi
Topic Covered :
Mitral Regurgitation Basics
Etiology
Acute MR
Chronic MR
Pathogenesis
Clinical Manifestations
Physical Signs
Diagnosis
Treatment : Medical Therapy & Surgical Therapy
MITRAL REGURGITATION
Mitral regurgitation is backflow of blood from the left ventricle into the left atrium, due to inadequate functioning (insufficiency) of the mitral valve, most commonly from ischemia. Men more than women.
The etiology of mitral regurgitation is due to abnormalities of the mitral leaflets, annulus, and chordae tendineae. Common causes include hypertension, CHF, ischemic heart disease, rheumatic fever, and any cause of dilation of the left ventricle.
Acute MR :
Rupture chordae tendineae (permits prolapse of a portion of a mitral valve leaflet into the left atrium)
Papillary muscle rupture
Endocarditis (may lead to valvular destruction)
Trauma
Chronic :
Rheumatic heart disease (causing scarring and retraction of valve and leaflets)
Papillary muscle dysfunction
Mitral valve prolapse (click-murmur syndrome, Barlow syndrome, floppy mitral valve)
Endocarditis
Calcification of the mitral valve annulus Accompanying hypertrophic obstructive cardiomyopathy
Congenital endocardial cushion defect, corrected transposition
Endocardial fibroelastosis
Severe left ventricular dilatation
Pathogenesis
A portion of the left ventricular stroke volume is pumped backward into the left atrium instead of forward into the aorta, resulting in increased left atrial pressure and decreased forward cardiac output.
Traditional measurement of the cardiac output by EF may be normal, since the LV empties well. It is just not all in the correct direction. A regurgitant fraction needs to be estimated by Doppler during echocardiography. Volume overload occurs, increasing preload.
Afterload is decreased as the left ventricle empties part of its contents into the relatively low-pressure left atrium.
This helps to compensate for the regurgitation by augmenting ejection fraction.
Left ventricular dysfunction occurs after prolonged compensation.
Clinical Manifestations
Left ventricular failure is manifested by dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.
Severe and chronic mitral regurgitation lead to right-sided failure, presenting with edema, ascites, anorexia, and fatigue.
Pulmonary hypertension may be a late finding.
Physical Signs
Hyperdynamic and displaced (downward and to the left) left ventricular impulse
Carotid upstroke diminished in volume but brisk
Holosystolic apical murmur radiating to the axilla and often accompanied by a thrill
S3 heard with a soft S1 and widely split S2 Distended neck veins when severe or acute
Diagnosis
EKG shows signs of left ventricular hypertrophy and left atrial enlargement. Chest x-ray shows cardiac enlargement, with vascular congestion when the regurgitation has led to heart failure.
Echocardiography (best first test): The mitral valve can prolapse into the left atrium during systole in cases of a ruptured chordae or mitral valve prolapse. Regardless of the cause, left atrial and left ventricular enlargement occurs if the condition is chronic.
Left-heart catheterization is the single most accurate test.
Treatment. Medical therapy. The goal is to relieve symptoms by increasing forward cardiac output and reducing pulmonary venous hypertension. ARBs/hydralazine, arteriolar vasodilators (ACE inhibitors), digitalis, and diuretics are used.
Surgical therapy. Mitral valve replacement is indicated when symptoms persist despite optimal medical management.
Indicated with significantly limiting symptoms and severe mitral regurgitation; the risk of surgery rises in chronic heart failure.
Indicated when symptoms persist despite optimal medical management. Repair is preferable to replacement.
Patients with regurgitation but few symptoms should defer surgery, as their condition may remain stable for years.
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