II. Precautions

  1. Evaluation and management here focuses on chronic Mitral Regurgitation
  2. Acute Mitral Regurgitation with papillary muscle rupture is also described, but requires emergent management

III. Pathophysiology

  1. Dysfunction of any of the mitral valve structure may result in Mitral Regurgitation
    1. Mitral valve leaflets
    2. Chordae Tendinae
    3. Papillary muscles
    4. Mitral annulus
  2. Chronic Early or compensated Mitral Regurgitation
    1. Volume overload
    2. Left Ventricular Hypertrophy
    3. Left atrial enlargement
  3. Chronic Late or decompensated Mitral Regurgitation
    1. Left Ventricular Failure
    2. Decreased ejection fraction
    3. Pulmonary congestion
  4. Acute Mitral Regurgitation due to papillary muscle rupture
    1. Typically affects posteromedial papillary muscle (most tenuous blood supply)

IV. Causes: Acute Mitral Regurgitation (due to papillary muscle rupture)

  1. Common causes of papillary muscle rupture
    1. Acute Myocardial Infarction
      1. Associated with 50% acute mortality rate
  2. Rare causes of papillary muscle rupture
    1. Infective Endocarditis
    2. Mitral Valve Prolapse

V. Causes: Chronic Mitral Regurgitation

  1. Rheumatic Heart Disease (50%)
  2. Mitral Valve Prolapse
  3. Ischemic Heart Disease and papillary muscle dysfunction
  4. Left Ventricular dilatation
  5. Mitral annular calcification
  6. Hypertrophic Cardiomyopathy
  7. Infective Endocarditis
  8. Congenital Mitral Regurgitation

VI. Symptoms

  1. Dyspnea
  2. Fatigue
  3. Weakness
  4. Cough

VII. Signs

  1. Holosystolic Murmur at Apex
    1. Harsh, medium pitched pansystolic murmur (without respiratory variation)
    2. Murmur obliterates M1
    3. Radiation
      1. Axilla
      2. Upper sternal borders
      3. Subscapular region
    4. Modifiers
      1. Murmur intensity decreases with squatting
      2. Murmur intensity increases with standing
  2. Other heart sounds
    1. Soft or diminished First Heart Sound (S1)
    2. P2 heart sound augmented
    3. S2 Heart Sound with wide split
    4. S3 Gallop rhythm (indicative of severe disease)
  3. Other findings
    1. Accentuated, hyperdynamic and displaced precordial Apical Thrust
    2. Systolic thrill
    3. Sharp carotid upstroke (contrast with the delayed and decreased pulsation of Aortic Stenosis)

VIII. Diagnostics: Electrocardiogram

IX. Imaging

  1. Chest XRay
    1. Enlarged left atrium
    2. Dilated left ventricle
  2. Echocardiogram
    1. Most important study in the evaluation of Mitral Regurgitation
    2. Test Sensitivity: 65-85%
    3. Associated Findings
      1. Enlarged left atrium
      2. Hyperdynamic left ventricle
      3. Doppler assesses severity

X. Monitoring

  1. Annual or semi-annual Echocardiogram
    1. Assess ejection fraction
    2. Assess end-systolic dimension

XI. Management

  1. SBE Prophylaxis
  2. Anticoagulation in Atrial Fibrillation
  3. Treat Congestive Heart Failure
    1. Diuretics
    2. Digoxin
    3. Afterload reduction
      1. ACE Inhibitor
      2. Hydralazine
      3. Nitroprusside IV
      4. Milrinone (also inotropic)
  4. Surgery: Mitral Valve repair or replacement
    1. Repair before Heart Failure develops
      1. Keep ejection fraction >60%
      2. Keep end-systolic dimension <45 mm
    2. Indications
      1. Cardiopulmonary Symptoms
      2. Left Ventricular function impaired

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Ontology: Mitral Valve Insufficiency (C0026266)

Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (CHV) blood flows backward because the mitral valve closes improperly
Definition (NCI) The backward flow of blood from the left ventricle into the left atrium, owing to insufficiency of the mitral valve; it may be acute or chronic, usually due to mitral valve prolapse, rheumatic heart disease or a complication of cardiac dilatation.
Definition (NCI_FDA) The backward flow of blood from the left ventricle into the left atrium, owing to insufficiency of the mitral valve; it may be acute or chronic, usually due to mitral valve prolapse, rheumatic heart disease or a complication of cardiac dilatation.
Definition (NCI) Dysfunction of the mitral valve characterized by incomplete valve closure.
Definition (CSP) backflow of blood from the left ventricle into the left atrium, owing to imperfect functioning of the mitral valve.
Definition (MSH) Backflow of blood from the LEFT VENTRICLE into the LEFT ATRIUM due to imperfect closure of the MITRAL VALVE. This can lead to mitral valve regurgitation.
Concepts Disease or Syndrome (T047)
MSH D008944
ICD10 I34.0
SnomedCT 194977007, 48724000
English Mitral Regurgitation, Mitral Insufficiency, Mitral Valve Insufficiency, Valve Insufficiency, Mitral, Mitral Valve Regurgitation, Mitral Incompetence, Mitral Valve Incompetence, Incompetence, Mitral, Incompetence, Mitral Valve, Regurgitation, Mitral, Regurgitation, Mitral Valve, Valve Incompetence, Mitral, Valve Regurgitation, Mitral, Insufficiency, Mitral, Insufficiency, Mitral Valve, Mitral incompetence, mitral valve insufficiency, Mitral (valve) insufficiency, MITRAL VALVE INCOMPETENCE, mitral regurgitation (diagnosis), mitral regurgitation, Mitral Valve Insufficiency [Disease/Finding], mitral regurgitation (MR), mitral valve regurgitation, mitral valve incompetence, Incompetence;mitral, mrs, mitral insufficiency, mitral regurgitations, MITRAL REGURGITATION, MITRAL INSUFFICIENCY, REGURGITATION, MITRAL, INSUFFICIENCY, MITRAL, Mitral insufficiency, Mitral regurgitation, Mitral valve insufficiency, MI - Mitral incompetence, MR - Mitral regurgitation, Mitral valve regurgitation, Mitral valve incompetence, Mitral valve regurgitation (disorder), insufficiency; mitral, mitral; insufficiency, Mitral valve incompetence, NOS, Mitral valve insufficiency, NOS, Mitral valve regurgitation, NOS, Mitral regurgitation, NOS, mitral incompetence
French INSUFFISANCE MITRALE, Régurgitation mitrale, Insuffisance valvulaire mitrale, INCOMPETENCE MITRALE, Insuffisance mitrale, Insuffisance de la valve mitrale
Italian Insufficienza della valvola mitrale, Rigurgito mitralico, Incompetenza mitralica, Insufficienza della valvola mitralica, Insufficienza mitralica
Dutch mitralisinsufficiëntie, mitralisregurgitatie, insufficiëntie van de mitralisklep, insufficiëntie; mitraal, mitraal; insufficiëntie, Mitralis(klep)insufficiëntie, mitralisklepinsufficiëntie, Mitralisrerurgitatie, Insufficiëntie, mitralisklep-, Mitralisinsufficiëntie, Mitralisklepinsufficiëntie
Portuguese Insuficiência mitral, Regurgitação mitral, INSUFICIENCIA DA VALVULA MITRAL, INSUFICIENCIA MITRAL, Insuficiência da válvula mitral, Incompetência da Valva Mitral, Incompetência Mitral, Insuficiência da Valva Mitral, Regurgitação Mitral
Spanish Incompetencia mitral, Regurgitación mitral, Insuficiencia mitral, INSUFICIENCIA MITRAL, Insuficiencia valvular mitral, incompetencia de la válvula mitral, insuficiencia de la válvula mitral (trastorno), insuficiencia de la válvula mitral, insuficiencia mitral, Insuficiencia de la válvula mitral, Incompetencia de la Válvula Mitral, Incompetencia Mitral, Insuficiencia de la Válvula Mitral, Regurgitación Mitral
Japanese 僧帽弁不全, ソウボウベンギャクリュウ, ソウボウベンヘイサフゼンショウ, ソウボウベンフゼン, 左房室弁閉鎖不全, 僧帽弁閉鎖不全症, ソウボウベンヘイサフゼン, 僧帽弁逆流, 僧帽弁閉鎖不全, 左房室弁閉鎖不全症, 僧帽弁逆流症
Swedish Mitralklaffinsufficiens
Czech mitrální chlopeň - insuficience, Inkompetence mitrální chlopně, Mitrální regurgitace, Mitrální insuficience, Mitrální inkompetence, insuficience mitrální chlopně, regurgitace mitrální chlopně, Insuficience mitrální chlopně
Finnish Hiippaläpän vuoto
Russian MITRAL'NOGO KLAPANA NEDOSTATOCHNOST', МИТРАЛЬНОГО КЛАПАНА НЕДОСТАТОЧНОСТЬ
German MITRALINSUFFIZIENZ, Mitralinsuffizienz, Mitralklappeninsuffizienz, Mitralregurgitation, Mitralklappenschlußunfähigkeit
Korean 승모(판) 폐쇄부전
Croatian MITRALNA INSUFICIJENCIJA
Polish Wada mitralna, Niedomykalność mitralna, Niedomykalność zastawki mitralnej
Hungarian Mitralis incompetentia, Mitralis regurgitatio, Mitralis insufficientia, Mitralis billentyű incompetentia, Mitralis billentyű elégtelensége
Norwegian Mitralinsuffisiens

Ontology: Mitral papillary muscle rupture (C0238414)

Concepts Disease or Syndrome (T047)
SnomedCT 266250003
English RUPTURED MITRAL PAPILLARY MUSCLE, Mitral papillary muscle rupt, mitral valve disorder papillary muscle rupture, Mitral papillary muscle rupture (diagnosis), Mitral papillary muscle rupture, Mitral papillary muscle rupture (disorder)
Spanish ruptura del músculo papilar mitral (trastorno), ruptura del músculo papilar mitral